{ "hospital_name": "Corpus Christi Rehabilitation Hospital", "last_updated_on": "2026-03-17", "version": "3.0.0", "location_name": [ "Corpus Christi Rehabilitation Hospital" ], "hospital_address": [ "5726 Esplanade Dr, Corpus Christi, TX 78414" ], "license_information": { "state": "TX" }, "type_2_npi": [ "1821439183" ], "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": "Traumatic spinal cord injury M >=56.50- Tier Tier 1", "code_information": [ { "code": "B0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=56.50- Tier Tier 2", "code_information": [ { "code": "C0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=56.50- Tier Tier 3", "code_information": [ { "code": "D0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Health Insurance Prospective Payment System (HIPPS) - Inpatient Rehabilitation Facility", "code_information": [ { "code": "0024", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=72.50- Tier None", "code_information": [ { "code": "A0101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=72.50- Tier Tier 1", "code_information": [ { "code": "B0101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=72.50- Tier Tier 2", "code_information": [ { "code": "C0101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=72.50- Tier Tier 3", "code_information": [ { "code": "D0101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 14429.82, "10th_percentile": 14429.82, "90th_percentile": 14429.82, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 14429.82, "maximum": 14429.82 } ] }, { "description": "Stroke M >=63.50 and M <72.50- Tier None", "code_information": [ { "code": "A0102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=63.50 and M <72.50- Tier Tier 1", "code_information": [ { "code": "B0102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=63.50 and M <72.50- Tier Tier 2", "code_information": [ { "code": "C0102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=63.50 and M <72.50- Tier Tier 3", "code_information": [ { "code": "D0102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=50.50 and M <63.50- Tier None", "code_information": [ { "code": "A0103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 22489.99, "10th_percentile": 22489.99, "90th_percentile": 22489.99, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22489.99, "10th_percentile": 19818.08, "90th_percentile": 22489.99, "count": "1 through 10" } ], "minimum": 22489.99, "maximum": 22489.99 } ] }, { "description": "Stroke M >=50.50 and M <63.50- Tier Tier 1", "code_information": [ { "code": "B0103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=50.50 and M <63.50- Tier Tier 2", "code_information": [ { "code": "C0103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=50.50 and M <63.50- Tier Tier 3", "code_information": [ { "code": "D0103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23128.26, "10th_percentile": 23128.26, "90th_percentile": 23128.26, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23600.27, "10th_percentile": 23600.27, "90th_percentile": 23600.27, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23959.27, "10th_percentile": 23959.27, "90th_percentile": 23959.27, "count": "1 through 10" } ], "minimum": 23128.26, "maximum": 23959.27 } ] }, { "description": "Stroke M >=41.50 and M <50.50- Tier None", "code_information": [ { "code": "A0104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 28703.43, "10th_percentile": 28703.43, "90th_percentile": 28703.43, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 28703.43, "10th_percentile": 28703.43, "90th_percentile": 28703.43, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28703.43, "maximum": 28703.43 } ] }, { "description": "Stroke M >=41.50 and M <50.50- Tier Tier 1", "code_information": [ { "code": "B0104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=41.50 and M <50.50- Tier Tier 2", "code_information": [ { "code": "C0104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32958.54, "10th_percentile": 32958.54, "90th_percentile": 32958.54, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32958.54, "maximum": 32958.54 } ] }, { "description": "Stroke M >=41.50 and M <50.50- Tier Tier 3", "code_information": [ { "code": "D0104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 30118.7, "10th_percentile": 30118.7, "90th_percentile": 30602.27, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 30118.7, "10th_percentile": 30118.7, "90th_percentile": 30118.7, "count": "1 through 10" } ], "minimum": 30118.7, "maximum": 30118.7 } ] }, { "description": "Stroke M <41.50 and A >=84.50- Tier None", "code_information": [ { "code": "A0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 36174.54, "10th_percentile": 35893.23, "90th_percentile": 36174.54, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23433.78, "10th_percentile": 23433.78, "90th_percentile": 36174.54, "count": "1 through 10" } ], "minimum": 23433.78, "maximum": 36174.54 } ] }, { "description": "Stroke M <41.50 and A >=84.50- Tier Tier 1", "code_information": [ { "code": "B0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M <41.50 and A >=84.50- Tier Tier 2", "code_information": [ { "code": "C0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M <41.50 and A >=84.50- Tier Tier 3", "code_information": [ { "code": "D0105", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 37661.86, "10th_percentile": 37661.86, "90th_percentile": 37661.86, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 37661.86, "maximum": 37661.86 } ] }, { "description": "Stroke M <41.50 and A <84.50- Tier None", "code_information": [ { "code": "A0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 32617.37, "10th_percentile": 32617.37, "90th_percentile": 32617.37, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 40823.44, "10th_percentile": 6212.26, "90th_percentile": 40823.44, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28216.29, "10th_percentile": 17438.24, "90th_percentile": 40823.44, "count": "1 through 10" } ], "minimum": 28216.29, "maximum": 40823.44 } ] }, { "description": "Stroke M <41.50 and A <84.50- Tier Tier 1", "code_information": [ { "code": "B0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 54051.86, "10th_percentile": 54051.86, "90th_percentile": 54051.86, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 54051.86, "maximum": 54051.86 } ] }, { "description": "Stroke M <41.50 and A <84.50- Tier Tier 2", "code_information": [ { "code": "C0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M <41.50 and A <84.50- Tier Tier 3", "code_information": [ { "code": "D0106", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 38041.82, "10th_percentile": 38041.82, "90th_percentile": 38041.82, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 42837.55, "10th_percentile": 42837.55, "90th_percentile": 42837.55, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 21812.53, "10th_percentile": 21812.53, "90th_percentile": 42837.55, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 21812.53, "10th_percentile": 21812.53, "90th_percentile": 42837.55, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 21812.53, "10th_percentile": 21812.53, "90th_percentile": 42837.55, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 42837.55, "10th_percentile": 42837.55, "90th_percentile": 42958.92, "count": "16" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 41653.68, "10th_percentile": 21431.66, "90th_percentile": 42958.92, "count": "1 through 10" } ], "minimum": 21812.53, "maximum": 42837.55 } ] }, { "description": "Traumatic brain injury M >=73.50- Tier None", "code_information": [ { "code": "A0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=73.50- Tier Tier 1", "code_information": [ { "code": "B0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=73.50- Tier Tier 2", "code_information": [ { "code": "C0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=73.50- Tier Tier 3", "code_information": [ { "code": "D0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=61.50 and M <73.50- Tier None", "code_information": [ { "code": "A0202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=61.50 and M <73.50- Tier Tier 1", "code_information": [ { "code": "B0202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=61.50 and M <73.50- Tier Tier 2", "code_information": [ { "code": "C0202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=61.50 and M <73.50- Tier Tier 3", "code_information": [ { "code": "D0202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=49.50 and M <61.50- Tier None", "code_information": [ { "code": "A0203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 21753.53, "10th_percentile": 21753.53, "90th_percentile": 21753.53, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 21753.53, "10th_percentile": 21753.53, "90th_percentile": 21753.53, "count": "1 through 10" } ], "minimum": 21753.53, "maximum": 21753.53 } ] }, { "description": "Traumatic brain injury M >=49.50 and M <61.50- Tier Tier 1", "code_information": [ { "code": "B0203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic brain injury M >=49.50 and M <61.50- Tier Tier 2", "code_information": [ { "code": "C0203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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", "median_amount": 25439.56, "10th_percentile": 25439.56, "90th_percentile": 25439.56, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 25439.56, "10th_percentile": 25439.56, "90th_percentile": 25439.56, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25439.56, "maximum": 25439.56 } ] }, { "description": "Traumatic brain injury M >=49.50 and M <61.50- Tier Tier 3", "code_information": [ { "code": "D0203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23105.57, "10th_percentile": 23105.57, "90th_percentile": 23105.57, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23105.57, "maximum": 23105.57 } ] }, { "description": "Traumatic brain injury M >=35.50 and M <49.50- Tier None", "code_information": [ { "code": "A0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 26981.3, "10th_percentile": 26981.3, "90th_percentile": 26981.3, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26981.3, "10th_percentile": 26981.3, "90th_percentile": 26981.3, "count": "1 through 10" } ], "minimum": 26981.3, "maximum": 26981.3 } ] }, { "description": "Traumatic brain injury M >=35.50 and M <49.50- Tier Tier 1", "code_information": [ { "code": "B0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 40037.06, "10th_percentile": 40037.06, "90th_percentile": 40037.06, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 40037.06, "maximum": 40037.06 } ] }, { "description": "Traumatic brain injury M >=35.50 and M <49.50- Tier Tier 2", "code_information": [ { "code": "C0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20917.8, "10th_percentile": 20917.8, "90th_percentile": 30921.52, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 31552.57, "10th_percentile": 31552.57, "90th_percentile": 31552.57, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23445.3, "10th_percentile": 23445.3, "90th_percentile": 31552.57, "count": "1 through 10" } ], "minimum": 20917.8, "maximum": 31552.57 } ] }, { "description": "Traumatic brain injury M >=35.50 and M <49.50- Tier Tier 3", "code_information": [ { "code": "D0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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", "median_amount": 28656.93, "10th_percentile": 28656.93, "90th_percentile": 28656.93, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 28656.93, "10th_percentile": 28656.93, "90th_percentile": 29082.9, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28656.93, "maximum": 28656.93 } ] }, { "description": "Traumatic brain injury M <35.50- Tier None", "code_information": [ { "code": "A0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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", "median_amount": 2879.98, "10th_percentile": 2879.98, "90th_percentile": 2879.98, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 34559.79, "10th_percentile": 2879.98, "90th_percentile": 34559.79, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 2879.98, "maximum": 34559.79 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 1", "code_information": [ { "code": "B0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 49069.58, "10th_percentile": 49069.58, "90th_percentile": 49069.58, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 49069.58, "maximum": 49069.58 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 2", "code_information": [ { "code": "C0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 40023.3, "10th_percentile": 40023.3, "90th_percentile": 40023.3, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 40414.29, "10th_percentile": 40414.29, "90th_percentile": 40414.29, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 40414.29, "10th_percentile": 6429.55, "90th_percentile": 40840.1, "count": "18" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33536.85, "10th_percentile": 33536.85, "90th_percentile": 40414.29, "count": "1 through 10" } ], "minimum": 33536.85, "maximum": 40414.29 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 3", "code_information": [ { "code": "D0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 37311.24, "10th_percentile": 37311.24, "90th_percentile": 37311.24, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 37311.24, "maximum": 37311.24 } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier None", "code_information": [ { "code": "A0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier Tier 1", "code_information": [ { "code": "B0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier Tier 2", "code_information": [ { "code": "C0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier Tier 3", "code_information": [ { "code": "D0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M >=52.50 and M <65.50- Tier None", "code_information": [ { "code": "A0302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 19964.45, "10th_percentile": 19964.45, "90th_percentile": 19964.45, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19964.45, "maximum": 19964.45 } ] }, { "description": "Non-traumatic brain injury M >=52.50 and M <65.50- Tier Tier 1", "code_information": [ { "code": "B0302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M >=52.50 and M <65.50- Tier Tier 2", "code_information": [ { "code": "C0302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23060.94, "10th_percentile": 23060.94, "90th_percentile": 23060.94, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23060.94, "maximum": 23060.94 } ] }, { "description": "Non-traumatic brain injury M >=52.50 and M <65.50- Tier Tier 3", "code_information": [ { "code": "D0302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 21182.59, "10th_percentile": 21182.59, "90th_percentile": 21182.59, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21182.59, "maximum": 21182.59 } ] }, { "description": "Non-traumatic brain injury M >=42.50 and M <52.50- Tier None", "code_information": [ { "code": "A0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 24022.43, "10th_percentile": 24022.43, "90th_percentile": 24022.43, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24022.43, "maximum": 24022.43 } ] }, { "description": "Non-traumatic brain injury M >=42.50 and M <52.50- Tier Tier 1", "code_information": [ { "code": "B0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 34680.67, "10th_percentile": 34680.67, "90th_percentile": 34680.67, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34680.67, "maximum": 34680.67 } ] }, { "description": "Non-traumatic brain injury M >=42.50 and M <52.50- Tier Tier 2", "code_information": [ { "code": "C0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 27745.66, "10th_percentile": 27745.66, "90th_percentile": 27745.66, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27745.66, "10th_percentile": 27745.66, "90th_percentile": 27745.66, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27745.66, "maximum": 27745.66 } ] }, { "description": "Non-traumatic brain injury M >=42.50 and M <52.50- Tier Tier 3", "code_information": [ { "code": "D0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 25487.92, "10th_percentile": 25487.92, "90th_percentile": 25487.92, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 25487.92, "10th_percentile": 25487.92, "90th_percentile": 25487.92, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25487.92, "maximum": 25487.92 } ] }, { "description": "Non-traumatic brain injury M <42.50 and A >=78.50- Tier None", "code_information": [ { "code": "A0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27853.52, "10th_percentile": 27853.52, "90th_percentile": 27853.52, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27853.52, "maximum": 27853.52 } ] }, { "description": "Non-traumatic brain injury M <42.50 and A >=78.50- Tier Tier 1", "code_information": [ { "code": "B0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M <42.50 and A >=78.50- Tier Tier 2", "code_information": [ { "code": "C0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 32323.34, "10th_percentile": 32323.34, "90th_percentile": 32323.34, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32170.01, "10th_percentile": 32170.01, "90th_percentile": 32323.34, "count": "23" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 32170.01, "10th_percentile": 32170.01, "90th_percentile": 32170.01, "count": "1 through 10" } ], "minimum": 32170.01, "maximum": 32323.34 } ] }, { "description": "Non-traumatic brain injury M <42.50 and A >=78.50- Tier Tier 3", "code_information": [ { "code": "D0304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M <42.50 and A <78.50- Tier None", "code_information": [ { "code": "A0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 30717.54, "10th_percentile": 30717.54, "90th_percentile": 30717.54, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30717.54, "maximum": 30717.54 } ] }, { "description": "Non-traumatic brain injury M <42.50 and A <78.50- Tier Tier 1", "code_information": [ { "code": "B0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M <42.50 and A <78.50- Tier Tier 2", "code_information": [ { "code": "C0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 35478.51, "10th_percentile": 35478.51, "90th_percentile": 35478.51, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 35478.51, "10th_percentile": 35407.32, "90th_percentile": 35478.51, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22046.49, "10th_percentile": 6522.4, "90th_percentile": 35478.51, "count": "1 through 10" } ], "minimum": 22046.49, "maximum": 35478.51 } ] }, { "description": "Non-traumatic brain injury M <42.50 and A <78.50- Tier Tier 3", "code_information": [ { "code": "D0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32590.31, "10th_percentile": 32590.31, "90th_percentile": 33009.51, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32590.31, "maximum": 32590.31 } ] }, { "description": "Traumatic spinal cord injury M >=56.50- Tier None", "code_information": [ { "code": "A0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M >=63.50- Tier Tier 1", "code_information": [ { "code": "B0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M >=63.50- Tier Tier 2", "code_information": [ { "code": "C0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M >=63.50- Tier Tier 3", "code_information": [ { "code": "D0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M >=51.50 and M <63.50- Tier None", "code_information": [ { "code": "A0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 19012.26, "10th_percentile": 19012.26, "90th_percentile": 19012.26, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19012.26, "maximum": 19012.26 } ] }, { "description": "Other orthopedic M >=51.50 and M <63.50- Tier Tier 1", "code_information": [ { "code": "B0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M >=51.50 and M <63.50- Tier Tier 2", "code_information": [ { "code": "C0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 22294.72, "10th_percentile": 22294.72, "90th_percentile": 22294.72, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22294.72, "maximum": 22294.72 } ] }, { "description": "Other orthopedic M >=51.50 and M <63.50- Tier Tier 3", "code_information": [ { "code": "D0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 20779.02, "10th_percentile": 20779.02, "90th_percentile": 20779.02, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 20779.02, "10th_percentile": 20779.02, "90th_percentile": 20779.02, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 13535.65, "10th_percentile": 13535.65, "90th_percentile": 13535.65, "count": "1 through 10" } ], "minimum": 13535.65, "maximum": 20779.02 } ] }, { "description": "Other orthopedic M >=44.50 and M <51.50- Tier None", "code_information": [ { "code": "A0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 22703.86, "10th_percentile": 22703.86, "90th_percentile": 22973.38, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 17478.62, "10th_percentile": 17478.62, "90th_percentile": 22703.86, "count": "1 through 10" } ], "minimum": 17478.62, "maximum": 22703.86 } ] }, { "description": "Other orthopedic M >=44.50 and M <51.50- Tier Tier 1", "code_information": [ { "code": "B0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M >=44.50 and M <51.50- Tier Tier 2", "code_information": [ { "code": "C0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 26622.36, "10th_percentile": 26622.36, "90th_percentile": 26622.36, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26622.36, "maximum": 26622.36 } ] }, { "description": "Other orthopedic M >=44.50 and M <51.50- Tier Tier 3", "code_information": [ { "code": "D0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 24814.68, "10th_percentile": 24814.68, "90th_percentile": 24814.68, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24814.68, "maximum": 24814.68 } ] }, { "description": "Other orthopedic M <44.5- Tier None", "code_information": [ { "code": "A0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 27204.47, "10th_percentile": 27204.47, "90th_percentile": 27204.47, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27204.47, "10th_percentile": 27204.47, "90th_percentile": 27204.47, "count": "11" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27204.47, "maximum": 27204.47 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 1", "code_information": [ { "code": "B0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 orthopedic M <44.5- Tier Tier 2", "code_information": [ { "code": "C0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 31900.34, "10th_percentile": 31900.34, "90th_percentile": 31900.34, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32100.9, "10th_percentile": 31900.34, "90th_percentile": 32100.9, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31900.34, "10th_percentile": 31900.34, "90th_percentile": 32100.9, "count": "1 through 10" } ], "minimum": 31900.34, "maximum": 32100.9 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 3", "code_information": [ { "code": "D0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 29733.73, "10th_percentile": 29733.73, "90th_percentile": 30323.28, "count": "14" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 29733.73, "10th_percentile": 22746.81, "90th_percentile": 29733.73, "count": "1 through 10" } ], "minimum": 29733.73, "maximum": 29733.73 } ] }, { "description": "Amputation lower extremity M >=64.50- Tier None", "code_information": [ { "code": "A1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=64.50- Tier Tier 1", "code_information": [ { "code": "B1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=64.50- Tier Tier 2", "code_information": [ { "code": "C1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=64.50- Tier Tier 3", "code_information": [ { "code": "D1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=55.50 and M <64.50- Tier None", "code_information": [ { "code": "A1002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=55.50 and M <64.50- Tier Tier 1", "code_information": [ { "code": "B1002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=55.50 and M <64.50- Tier Tier 2", "code_information": [ { "code": "C1002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=55.50 and M <64.50- Tier Tier 3", "code_information": [ { "code": "D1002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=47.50 and M <55.50- Tier None", "code_information": [ { "code": "A1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 22625.76, "10th_percentile": 22625.76, "90th_percentile": 22625.76, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22625.76, "maximum": 22625.76 } ] }, { "description": "Amputation lower extremity M >=47.50 and M <55.50- Tier Tier 1", "code_information": [ { "code": "B1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=47.50 and M <55.50- Tier Tier 2", "code_information": [ { "code": "C1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M >=47.50 and M <55.50- Tier Tier 3", "code_information": [ { "code": "D1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M <47.50- Tier None", "code_information": [ { "code": "A1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 28965.65, "10th_percentile": 28965.65, "90th_percentile": 28965.65, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28965.65, "maximum": 28965.65 } ] }, { "description": "Amputation lower extremity M <47.50- Tier Tier 1", "code_information": [ { "code": "B1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 44551.81, "10th_percentile": 44551.81, "90th_percentile": 44551.81, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42794.78, "10th_percentile": 42794.78, "90th_percentile": 42794.78, "count": "1 through 10" } ], "minimum": 42794.78, "maximum": 44551.81 } ] }, { "description": "Amputation lower extremity M <47.50- Tier Tier 2", "code_information": [ { "code": "C1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 35392.96, "10th_percentile": 35392.96, "90th_percentile": 35392.96, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 35392.96, "maximum": 35392.96 } ] }, { "description": "Amputation lower extremity M <47.50- Tier Tier 3", "code_information": [ { "code": "D1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 32329.95, "10th_percentile": 32329.95, "90th_percentile": 32329.95, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27962.1, "10th_percentile": 5535.75, "90th_percentile": 32927.54, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32329.95, "10th_percentile": 32329.95, "90th_percentile": 32329.95, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33599.53, "10th_percentile": 33599.53, "90th_percentile": 33599.53, "count": "1 through 10" } ], "minimum": 27962.1, "maximum": 33599.53 } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier None", "code_information": [ { "code": "A1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier Tier 1", "code_information": [ { "code": "B1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier Tier 2", "code_information": [ { "code": "C1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier Tier 3", "code_information": [ { "code": "D1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=52.50 and M <58.50- Tier None", "code_information": [ { "code": "A1102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=52.50 and M <58.50- Tier Tier 1", "code_information": [ { "code": "B1102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=52.50 and M <58.50- Tier Tier 2", "code_information": [ { "code": "C1102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M >=52.50 and M <58.50- Tier Tier 3", "code_information": [ { "code": "D1102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M <52.50- Tier None", "code_information": [ { "code": "A1103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M <52.50- Tier Tier 1", "code_information": [ { "code": "B1103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M <52.50- Tier Tier 2", "code_information": [ { "code": "C1103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation non-lower extremity M <52.50- Tier Tier 3", "code_information": [ { "code": "D1103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=61.50- Tier None", "code_information": [ { "code": "A1201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=61.50- Tier Tier 1", "code_information": [ { "code": "B1201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=61.50- Tier Tier 2", "code_information": [ { "code": "C1201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=61.50- Tier Tier 3", "code_information": [ { "code": "D1201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=47.50 and M <56.50- Tier None", "code_information": [ { "code": "A0402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=47.50 and M <56.50- Tier Tier 1", "code_information": [ { "code": "B0402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=47.50 and M <56.50- Tier Tier 2", "code_information": [ { "code": "C0402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=47.50 and M <56.50- Tier Tier 3", "code_information": [ { "code": "D0402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=41.50 and M <47.50- Tier None", "code_information": [ { "code": "A0403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=41.50 and M <47.50- Tier Tier 1", "code_information": [ { "code": "B0403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=41.50 and M <47.50- Tier Tier 2", "code_information": [ { "code": "C0403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=41.50 and M <47.50- Tier Tier 3", "code_information": [ { "code": "D0403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M <31.50 and A <61.50- Tier None", "code_information": [ { "code": "A0404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M <31.50 and A <61.50- Tier Tier 1", "code_information": [ { "code": "B0404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M <31.50 and A <61.50- Tier Tier 2", "code_information": [ { "code": "C0404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 50403.03, "10th_percentile": 50403.03, "90th_percentile": 50403.03, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 50403.03, "maximum": 50403.03 } ] }, { "description": "Traumatic spinal cord injury M <31.50 and A <61.50- Tier Tier 3", "code_information": [ { "code": "D0404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=31.50 and M <41.50- Tier None", "code_information": [ { "code": "A0405", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 35355.76, "10th_percentile": 35355.76, "90th_percentile": 35355.76, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 35355.76, "maximum": 35355.76 } ] }, { "description": "Traumatic spinal cord injury M >=31.50 and M <41.50- Tier Tier 1", "code_information": [ { "code": "B0405", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=31.50 and M <41.50- Tier Tier 2", "code_information": [ { "code": "C0405", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=31.50 and M <41.50- Tier Tier 3", "code_information": [ { "code": "D0405", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=24.50 and M <31.50 and A >=61.50- Tier None", "code_information": [ { "code": "A0406", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=24.50 and M <31.50 and A >=61.50- Tier Tier 1", "code_information": [ { "code": "B0406", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=24.50 and M <31.50 and A >=61.50- Tier Tier 2", "code_information": [ { "code": "C0406", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M >=24.50 and M <31.50 and A >=61.50- Tier Tier 3", "code_information": [ { "code": "D0406", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M <24.50 and A >=61.50- Tier None", "code_information": [ { "code": "A0407", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M <24.50 and A >=61.50- Tier Tier 1", "code_information": [ { "code": "B0407", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic spinal cord injury M <24.50 and A >=61.50- Tier Tier 2", "code_information": [ { "code": "C0407", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 69841.94, "10th_percentile": 69841.94, "90th_percentile": 69841.94, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 69841.94, "maximum": 69841.94 } ] }, { "description": "Traumatic spinal cord injury M <24.50 and A >=61.50- Tier Tier 3", "code_information": [ { "code": "D0407", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=60.50- Tier None", "code_information": [ { "code": "A0501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=60.50- Tier Tier 1", "code_information": [ { "code": "B0501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=60.50- Tier Tier 2", "code_information": [ { "code": "C0501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=60.50- Tier Tier 3", "code_information": [ { "code": "D0501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=53.50 and M <60.50- Tier None", "code_information": [ { "code": "A0502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=53.50 and M <60.50- Tier Tier 1", "code_information": [ { "code": "B0502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=53.50 and M <60.50- Tier Tier 2", "code_information": [ { "code": "C0502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=53.50 and M <60.50- Tier Tier 3", "code_information": [ { "code": "D0502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=48.50 and M <53.50- Tier None", "code_information": [ { "code": "A0503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=48.50 and M <53.50- Tier Tier 1", "code_information": [ { "code": "B0503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=48.50 and M <53.50- Tier Tier 2", "code_information": [ { "code": "C0503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=48.50 and M <53.50- Tier Tier 3", "code_information": [ { "code": "D0503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=39.50 and M <48.50- Tier None", "code_information": [ { "code": "A0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27342.09, "10th_percentile": 27342.09, "90th_percentile": 27342.09, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27342.09, "maximum": 27342.09 } ] }, { "description": "Non-traumatic spinal cord injury M >=39.50 and M <48.50- Tier Tier 1", "code_information": [ { "code": "B0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=39.50 and M <48.50- Tier Tier 2", "code_information": [ { "code": "C0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 31405.65, "10th_percentile": 31405.65, "90th_percentile": 31405.65, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31405.65, "maximum": 31405.65 } ] }, { "description": "Non-traumatic spinal cord injury M >=39.50 and M <48.50- Tier Tier 3", "code_information": [ { "code": "D0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M <39.50- Tier None", "code_information": [ { "code": "A0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 4749.11, "10th_percentile": 4749.11, "90th_percentile": 37992.89, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 37992.89, "10th_percentile": 37992.89, "90th_percentile": 37992.89, "count": "1 through 10" } ], "minimum": 4749.11, "maximum": 37992.89 } ] }, { "description": "Non-traumatic spinal cord injury M <39.50- Tier Tier 1", "code_information": [ { "code": "B0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 56095.73, "10th_percentile": 56095.73, "90th_percentile": 56095.73, "count": "1 through 10" } ], "minimum": 56095.73, "maximum": 56095.73 } ] }, { "description": "Non-traumatic spinal cord injury M <39.50- Tier Tier 2", "code_information": [ { "code": "C0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 43640.96, "10th_percentile": 43640.96, "90th_percentile": 43640.96, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 43640.96, "10th_percentile": 43640.96, "90th_percentile": 45258.71, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 43640.96, "maximum": 43640.96 } ] }, { "description": "Non-traumatic spinal cord injury M <39.50- Tier Tier 3", "code_information": [ { "code": "D0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 6698.52, "10th_percentile": 6559.14, "90th_percentile": 41228.86, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 41228.86, "10th_percentile": 41228.86, "90th_percentile": 41228.86, "count": "1 through 10" } ], "minimum": 6698.52, "maximum": 41228.86 } ] }, { "description": "Neurological M >=64.50- Tier None", "code_information": [ { "code": "A0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Neurological M >=64.50- Tier Tier 1", "code_information": [ { "code": "B0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Neurological M >=64.50- Tier Tier 2", "code_information": [ { "code": "C0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Neurological M >=64.50- Tier Tier 3", "code_information": [ { "code": "D0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 17271.53, "10th_percentile": 17271.53, "90th_percentile": 17271.53, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 17271.53, "10th_percentile": 17271.53, "90th_percentile": 17271.53, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17271.53, "maximum": 17271.53 } ] }, { "description": "Neurological M >=52.50 and M <64.50- Tier None", "code_information": [ { "code": "A0602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 19756.16, "10th_percentile": 19756.16, "90th_percentile": 19756.16, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19756.16, "maximum": 19756.16 } ] }, { "description": "Neurological M >=52.50 and M <64.50- Tier Tier 1", "code_information": [ { "code": "B0602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 31342.42, "10th_percentile": 31342.42, "90th_percentile": 31342.42, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31342.42, "maximum": 31342.42 } ] }, { "description": "Neurological M >=52.50 and M <64.50- Tier Tier 2", "code_information": [ { "code": "C0602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23466.36, "10th_percentile": 23466.36, "90th_percentile": 23466.36, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23466.36, "maximum": 23466.36 } ] }, { "description": "Neurological M >=52.50 and M <64.50- Tier Tier 3", "code_information": [ { "code": "D0602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 21906.03, "10th_percentile": 21906.03, "90th_percentile": 21906.03, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 21906.03, "10th_percentile": 21906.03, "90th_percentile": 21906.03, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 21906.03, "10th_percentile": 21906.03, "90th_percentile": 21906.03, "count": "1 through 10" } ], "minimum": 21906.03, "maximum": 21906.03 } ] }, { "description": "Neurological M >=43.50 and M <52.50- Tier None", "code_information": [ { "code": "A0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23278.53, "10th_percentile": 23278.53, "90th_percentile": 23278.53, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 12908.21, "10th_percentile": 12908.21, "90th_percentile": 12908.21, "count": "1 through 10" } ], "minimum": 12908.21, "maximum": 23278.53 } ] }, { "description": " Neurological M >=43.50 and M <52.50- Tier Tier 1", "code_information": [ { "code": "B0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 36930.98, "10th_percentile": 36930.98, "90th_percentile": 36930.98, "count": "1 through 10" } ], "minimum": 36930.98, "maximum": 36930.98 } ] }, { "description": "Neurological M >=43.50 and M <52.50- Tier Tier 2", "code_information": [ { "code": "C0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27648.95, "10th_percentile": 27648.95, "90th_percentile": 27654.01, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27648.95, "10th_percentile": 27648.95, "90th_percentile": 27648.95, "count": "1 through 10" } ], "minimum": 27648.95, "maximum": 27648.95 } ] }, { "description": "Neurological M >=43.50 and M <52.50- Tier Tier 3", "code_information": [ { "code": "D0603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 25811.51, "10th_percentile": 25811.51, "90th_percentile": 25811.51, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 25811.51, "10th_percentile": 4963.75, "90th_percentile": 25811.51, "count": "20" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20526.43, "10th_percentile": 20526.43, "90th_percentile": 20526.43, "count": "1 through 10" } ], "minimum": 20526.43, "maximum": 25811.51 } ] }, { "description": "Neurological M <43.50- Tier None", "code_information": [ { "code": "A0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 29194.4, "10th_percentile": 29194.4, "90th_percentile": 29588.1, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22630.41, "10th_percentile": 22630.41, "90th_percentile": 22630.41, "count": "1 through 10" } ], "minimum": 22630.41, "maximum": 29194.4 } ] }, { "description": "Neurological M <43.50- Tier Tier 1", "code_information": [ { "code": "B0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 46315.29, "10th_percentile": 46180.51, "90th_percentile": 46315.29, "count": "11" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 46315.29, "maximum": 46315.29 } ] }, { "description": "Neurological M <43.50- Tier Tier 2", "code_information": [ { "code": "C0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 34675.1, "10th_percentile": 34675.1, "90th_percentile": 34973.75, "count": "17" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34675.1, "maximum": 34675.1 } ] }, { "description": "Neurological M <43.50- Tier Tier 3", "code_information": [ { "code": "D0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 32370.86, "10th_percentile": 32370.86, "90th_percentile": 32370.86, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32370.86, "10th_percentile": 32370.86, "90th_percentile": 32941.64, "count": "25" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28429.45, "10th_percentile": 7081.13, "90th_percentile": 32941.64, "count": "1 through 10" } ], "minimum": 28429.45, "maximum": 32370.86 } ] }, { "description": "Fracture of lower extremity M >=61.50- Tier None", "code_information": [ { "code": "A0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fracture of lower extremity M >=61.50- Tier Tier 1", "code_information": [ { "code": "B0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fracture of lower extremity M >=61.50- Tier Tier 2", "code_information": [ { "code": "C0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fracture of lower extremity M >=61.50- Tier Tier 3", "code_information": [ { "code": "D0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fracture of lower extremity M >=52.50 and M <61.50- Tier None", "code_information": [ { "code": "A0702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 19505.09, "10th_percentile": 19505.09, "90th_percentile": 19505.09, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 19124.1, "10th_percentile": 19124.1, "90th_percentile": 19124.1, "count": "1 through 10" } ], "minimum": 19124.1, "maximum": 19505.09 } ] }, { "description": "Fracture of lower extremity M >=52.50 and M <61.50- Tier Tier 1", "code_information": [ { "code": "B0702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fracture of lower extremity M >=52.50 and M <61.50- Tier Tier 2", "code_information": [ { "code": "C0702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 22287.28, "10th_percentile": 22287.28, "90th_percentile": 22287.28, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22287.28, "maximum": 22287.28 } ] }, { "description": "Fracture of lower extremity M >=52.50 and M <61.50- Tier Tier 3", "code_information": [ { "code": "D0702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 21111.92, "10th_percentile": 21111.92, "90th_percentile": 21111.92, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20689.68, "10th_percentile": 20689.68, "90th_percentile": 20689.68, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 21111.92, "10th_percentile": 21111.92, "90th_percentile": 21111.92, "count": "1 through 10" } ], "minimum": 20689.68, "maximum": 21111.92 } ] }, { "description": "Fracture of lower extremity M >=41.50 and M <52.50- Tier None", "code_information": [ { "code": "A0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23987.09, "10th_percentile": 23987.09, "90th_percentile": 24302.36, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20966.78, "10th_percentile": 20966.78, "90th_percentile": 20966.78, "count": "1 through 10" } ], "minimum": 20966.78, "maximum": 23987.09 } ] }, { "description": "Fracture of lower extremity M >=41.50 and M <52.50- Tier Tier 1", "code_information": [ { "code": "B0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fracture of lower extremity M >=41.50 and M <52.50- Tier Tier 2", "code_information": [ { "code": "C0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27407.18, "10th_percentile": 27407.18, "90th_percentile": 27407.18, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27407.18, "maximum": 27407.18 } ] }, { "description": "Fracture of lower extremity M >=41.50 and M <52.50- Tier Tier 3", "code_information": [ { "code": "D0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 25962.15, "10th_percentile": 25962.15, "90th_percentile": 25962.15, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25962.15, "maximum": 25962.15 } ] }, { "description": "Fracture of lower extremity M <41.50- Tier None", "code_information": [ { "code": "A0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 29302.27, "10th_percentile": 29302.27, "90th_percentile": 29302.27, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 29302.27, "10th_percentile": 29302.27, "90th_percentile": 30006.59, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 29302.27, "10th_percentile": 29302.27, "90th_percentile": 29302.27, "count": "1 through 10" } ], "minimum": 29302.27, "maximum": 29302.27 } ] }, { "description": "Fracture of lower extremity M <41.50- Tier Tier 1", "code_information": [ { "code": "B0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 43282.03, "10th_percentile": 43282.03, "90th_percentile": 43282.03, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 6006.05, "10th_percentile": 6006.05, "90th_percentile": 6006.05, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 6006.05, "maximum": 43282.03 } ] }, { "description": "Fracture of lower extremity M <41.50- Tier Tier 2", "code_information": [ { "code": "C0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 33481.13, "10th_percentile": 33481.13, "90th_percentile": 33481.13, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 32811.51, "10th_percentile": 32811.51, "90th_percentile": 32811.51, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 33481.13, "10th_percentile": 33481.13, "90th_percentile": 34576, "count": "14" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32811.51, "maximum": 33481.13 } ] }, { "description": "Fracture of lower extremity M <41.50- Tier Tier 3", "code_information": [ { "code": "D0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 31716.23, "10th_percentile": 31716.23, "90th_percentile": 32837.96, "count": "23" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27486.23, "10th_percentile": 6529.81, "90th_percentile": 31716.23, "count": "1 through 10" } ], "minimum": 27486.23, "maximum": 31716.23 } ] }, { "description": "Replacement of lower-extremity joint M >=63.50- Tier None", "code_information": [ { "code": "A0801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=63.50- Tier Tier 1", "code_information": [ { "code": "B0801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=63.50- Tier Tier 2", "code_information": [ { "code": "C0801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=63.50- Tier Tier 3", "code_information": [ { "code": "D0801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=57.50 and M <63.50- Tier None", "code_information": [ { "code": "A0802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 17489.12, "10th_percentile": 17489.12, "90th_percentile": 17489.12, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17489.12, "maximum": 17489.12 } ] }, { "description": "Replacement of lower-extremity joint M >=57.50 and M <63.50- Tier Tier 1", "code_information": [ { "code": "B0802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=57.50 and M <63.50- Tier Tier 2", "code_information": [ { "code": "C0802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=57.50 and M <63.50- Tier Tier 3", "code_information": [ { "code": "D0802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=51.50 and M <57.50- Tier None", "code_information": [ { "code": "A0803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 19467.89, "10th_percentile": 19467.89, "90th_percentile": 19650, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19467.89, "maximum": 19467.89 } ] }, { "description": "Replacement of lower-extremity joint M >=51.50 and M <57.50- Tier Tier 1", "code_information": [ { "code": "B0803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=51.50 and M <57.50- Tier Tier 2", "code_information": [ { "code": "C0803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=51.50 and M <57.50- Tier Tier 3", "code_information": [ { "code": "D0803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 20872.01, "10th_percentile": 20872.01, "90th_percentile": 20872.01, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20872.01, "maximum": 20872.01 } ] }, { "description": "Replacement of lower-extremity joint M >=42.50 and M <51.50- Tier None", "code_information": [ { "code": "A0804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 21809.32, "10th_percentile": 21809.32, "90th_percentile": 21809.32, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 21809.32, "10th_percentile": 21809.32, "90th_percentile": 22323.03, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 16832.82, "10th_percentile": 16832.82, "90th_percentile": 16832.82, "count": "1 through 10" } ], "minimum": 16832.82, "maximum": 21809.32 } ] }, { "description": "Replacement of lower-extremity joint M >=42.50 and M <51.50- Tier Tier 1", "code_information": [ { "code": "B0804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=42.50 and M <51.50- Tier Tier 2", "code_information": [ { "code": "C0804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M >=42.50 and M <51.50- Tier Tier 3", "code_information": [ { "code": "D0804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23384.53, "10th_percentile": 23384.53, "90th_percentile": 23384.53, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23384.53, "maximum": 23384.53 } ] }, { "description": "Replacement of lower-extremity joint M <42.50- Tier None", "code_information": [ { "code": "A0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 27802.94, "10th_percentile": 27802.94, "90th_percentile": 27802.94, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 27802.94, "10th_percentile": 26157.43, "90th_percentile": 27802.94, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27802.94, "maximum": 27802.94 } ] }, { "description": "Replacement of lower-extremity joint M <42.50- Tier Tier 1", "code_information": [ { "code": "B0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Replacement of lower-extremity joint M <42.50- Tier Tier 2", "code_information": [ { "code": "C0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 30760.31, "10th_percentile": 30760.31, "90th_percentile": 33198.01, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 30760.31, "10th_percentile": 30760.31, "90th_percentile": 30760.31, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30760.31, "maximum": 30760.31 } ] }, { "description": "Replacement of lower-extremity joint M <42.50- Tier Tier 3", "code_information": [ { "code": "D0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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", "median_amount": 29674.81, "10th_percentile": 28045.08, "90th_percentile": 29674.81, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22569.14, "10th_percentile": 22569.14, "90th_percentile": 22569.14, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 28045.08, "10th_percentile": 28045.08, "90th_percentile": 29674.81, "count": "14" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22569.14, "maximum": 29674.81 } ] }, { "description": "Other orthopedic M >=63.50- Tier None", "code_information": [ { "code": "A0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=56.50 and M <68.50- Tier Tier 1", "code_information": [ { "code": "B1502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=56.50 and M <68.50- Tier Tier 2", "code_information": [ { "code": "C1502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=56.50 and M <68.50- Tier Tier 3", "code_information": [ { "code": "D1502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=45.50 and M <56.50- Tier None", "code_information": [ { "code": "A1503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=45.50 and M <56.50- Tier Tier 1", "code_information": [ { "code": "B1503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=45.50 and M <56.50- Tier Tier 2", "code_information": [ { "code": "C1503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M >=45.50 and M <56.50- Tier Tier 3", "code_information": [ { "code": "D1503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M <45.50- Tier None", "code_information": [ { "code": "A1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 30202.39, "10th_percentile": 30202.39, "90th_percentile": 30202.39, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30202.39, "maximum": 30202.39 } ] }, { "description": "Pulmonary M <45.50- Tier Tier 1", "code_information": [ { "code": "B1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M <45.50- Tier Tier 2", "code_information": [ { "code": "C1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 M <45.50- Tier Tier 3", "code_information": [ { "code": "D1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 32287.17, "10th_percentile": 32287.17, "90th_percentile": 33250.8, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32287.17, "maximum": 32287.17 } ] }, { "description": "Pain syndrome M >=65.50- Tier None", "code_information": [ { "code": "A1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=65.50- Tier Tier 1", "code_information": [ { "code": "B1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=65.50- Tier Tier 2", "code_information": [ { "code": "C1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=65.50- Tier Tier 3", "code_information": [ { "code": "D1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=58.50 and M <65.50- Tier None", "code_information": [ { "code": "A1602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=58.50 and M <65.50- Tier Tier 1", "code_information": [ { "code": "B1602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=58.50 and M <65.50- Tier Tier 2", "code_information": [ { "code": "C1602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=58.50 and M <65.50- Tier Tier 3", "code_information": [ { "code": "D1602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=43.50 and M <58.50- Tier None", "code_information": [ { "code": "A1603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=43.50 and M <58.50- Tier Tier 1", "code_information": [ { "code": "B1603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=43.50 and M <58.50- Tier Tier 2", "code_information": [ { "code": "C1603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M >=43.50 and M <58.50- Tier Tier 3", "code_information": [ { "code": "D1603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Room & Board - Private (One Bed) - Rehabilitation", "code_information": [ { "code": "0118", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "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": "Workers' Compensation", "standard_charge_percentage": 85, "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_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "PPO", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 1450, "methodology": "per diem", "median_amount": 1450, "10th_percentile": 1450, "90th_percentile": 1450, "count": "1 through 10" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "median_amount": 575, "10th_percentile": 575, "90th_percentile": 575, "count": "11" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "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 Texas", "plan_name": "HealthSelect", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 575, "maximum": 2450 } ] }, { "description": "Pain syndrome M <43.50- Tier None", "code_information": [ { "code": "A1604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M <43.50- Tier Tier 1", "code_information": [ { "code": "B1604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M <43.50- Tier Tier 2", "code_information": [ { "code": "C1604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pain syndrome M <43.50- Tier Tier 3", "code_information": [ { "code": "D1604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=57.50- Tier None", "code_information": [ { "code": "A1701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=57.50- Tier Tier 1", "code_information": [ { "code": "B1701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Rehabilitation", "code_information": [ { "code": "0128", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "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": "Workers' Compensation", "standard_charge_percentage": 85, "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_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "PPO", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 1450, "methodology": "per diem", "median_amount": 1450, "10th_percentile": 1450, "90th_percentile": 1450, "count": "1 through 10" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "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": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Three and Four Beds - Rehabilitation", "code_information": [ { "code": "0138", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "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": "Workers' Compensation", "standard_charge_percentage": 85, "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_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "PPO", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 1400, "methodology": "per diem", "median_amount": 1400, "10th_percentile": 1400, "90th_percentile": 1400, "count": "1 through 10" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "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": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Deluxe Private - Rehabilitation", "code_information": [ { "code": "0148", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "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": "Workers' Compensation", "standard_charge_percentage": 85, "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_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "PPO", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "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": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Ward - Rehabilitation", "code_information": [ { "code": "0158", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "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": "Workers' Compensation", "standard_charge_percentage": 85, "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_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "PPO", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "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": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Private (One Bed) - General Classification", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Private (One Bed) - Other", "code_information": [ { "code": "0119", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per 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diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - General Classification", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Other", "code_information": [ { "code": "0129", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": 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"per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Three and Four Beds - General Classification", "code_information": [ { "code": "0130", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Three and Four Beds - Other", "code_information": [ { "code": "0139", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Deluxe Private - General Classification", "code_information": [ { "code": "0140", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Deluxe Private - Other", "code_information": [ { "code": "0149", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Ward - General Classification", "code_information": [ { "code": "0150", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Room & Board - Ward - Other", "code_information": [ { "code": "0159", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1002, "methodology": "per diem", "median_amount": 1002, "10th_percentile": 1002, "90th_percentile": 1002, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Commercial", "standard_charge_dollar": 1035, "methodology": "per diem", "median_amount": 1035, "10th_percentile": 1035, "90th_percentile": 1035, "count": "1 through 10" } ], "minimum": 1002, "maximum": 1035 } ] }, { "description": "Subacute Care - General Classification", "code_information": [ { "code": "0190", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 300 } ] }, { "description": "Subacute Care - Level I", "code_information": [ { "code": "0191", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 297, "methodology": "per diem", "median_amount": 297, "10th_percentile": 297, "90th_percentile": 297, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 297, "methodology": "per diem", "median_amount": 297, "10th_percentile": 297, "90th_percentile": 297, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 297, "maximum": 300 } ] }, { "description": "Subacute Care - Level II", "code_information": [ { "code": "0192", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 446, "methodology": "per diem", "median_amount": 446, "10th_percentile": 446, "90th_percentile": 446, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 446, "methodology": "per diem", "median_amount": 446, "10th_percentile": 446, "90th_percentile": 446, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 446 } ] }, { "description": "Subacute Care - Level III", "code_information": [ { "code": "0193", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 744, "methodology": "per diem", "median_amount": 744, "10th_percentile": 744, "90th_percentile": 744, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 744, "methodology": "per diem", "median_amount": 744, "10th_percentile": 744, "90th_percentile": 744, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 744 } ] }, { "description": "Subacute Care - Level IV", "code_information": [ { "code": "0194", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 781, "methodology": "per diem", "median_amount": 781, "10th_percentile": 781, "90th_percentile": 781, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 781, "methodology": "per diem", "median_amount": 781, "10th_percentile": 781, "90th_percentile": 781, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 781 } ] }, { "description": "Medical Rehabilitation Day Program - Half Day", "code_information": [ { "code": "0931", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 one evaluation", "code_information": [ { "code": "90935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "92507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 107.78, "10th_percentile": 107.78, "90th_percentile": 107.78, "count": "32" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 73.22, "10th_percentile": 73.22, "90th_percentile": 73.22, "count": "1 through 10" } ], "minimum": 73.22, "maximum": 120 } ] }, { "description": "Speech sound lang comprehen", "code_information": [ { "code": "92523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 169.81, "10th_percentile": 169.81, "90th_percentile": 169.81, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 169.81, "10th_percentile": 169.81, "90th_percentile": 169.81, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 218.02, "10th_percentile": 218.02, "90th_percentile": 218.02, "count": "1 through 10" } ], "minimum": 120, "maximum": 218.02 } ] }, { "description": "Bone imaging whole body", "code_information": [ { "code": "78306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 dir opt obs", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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/o scope", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 folic acid serum", "code_information": [ { "code": "82746", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 w/o2 saturation", "code_information": [ { "code": "82805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 glucose blood quant", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 ggt", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 natriuretic peptide", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 osmolality", "code_information": [ { "code": "83930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 potassium", "code_information": [ { "code": "84132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 psa total", "code_information": [ { "code": "84153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 thyroid stim hormone", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 assay (ft-3)", "code_information": [ { "code": "84481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid factor quant", "code_information": [ { "code": "86431", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rubeola antibody", "code_information": [ { "code": "86765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treponema pallidum", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stool cultr aerobic bact ea", "code_information": [ { "code": "87046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 anaerobe ident each", "code_information": [ { "code": "87076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 aerobic identify", "code_information": [ { "code": "87077", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 culture/colony count", "code_information": [ { "code": "87086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 bacteria culture", "code_information": [ { "code": "87088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 diffuse", "code_information": [ { "code": "87181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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 covid-19 amp prb", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid 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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Oral function therapy", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Advantra", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 80.63, "10th_percentile": 80.63, "90th_percentile": 80.63, "count": "1 through 10" } ], "minimum": 80.63, "maximum": 120 } ] }, { "description": "Evaluate swallowing function", "code_information": [ { "code": "92610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.41, "10th_percentile": 67.41, "90th_percentile": 67.41, "count": "1 through 10" } ], "minimum": 67.41, "maximum": 67.41 } ] }, { "description": "Motion fluoroscopy/swallow", "code_information": [ { "code": "92611", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "93926", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 53.2, "10th_percentile": 26.6, "90th_percentile": 79.8, "count": "31" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 53.2, "10th_percentile": 26.6, "90th_percentile": 79.8, "count": "31" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 53.2, "10th_percentile": 26.6, "90th_percentile": 79.8, "count": "31" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 56, "10th_percentile": 28, "90th_percentile": 84, "count": "66" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 42.62, "10th_percentile": 42.62, "90th_percentile": 42.62, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "58" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 56, "10th_percentile": 28, "90th_percentile": 112, "count": "183" } ], "minimum": 33.75, "maximum": 120 } ] }, { "description": "Neuromuscular reeducation", "code_information": [ { "code": "97112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 59.18, "10th_percentile": 29.59, "90th_percentile": 59.18, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 59.18, "10th_percentile": 29.59, "90th_percentile": 59.18, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 59.18, "10th_percentile": 29.59, "90th_percentile": 59.18, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.15, "10th_percentile": 31.15, "90th_percentile": 62.3, "count": "30" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24.75, "10th_percentile": 24.75, "90th_percentile": 24.75, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.5, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "50" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.15, "10th_percentile": 31.15, "90th_percentile": 62.3, "count": "70" } ], "minimum": 24.75, "maximum": 120 } ] }, { "description": "Gait training therapy", "code_information": [ { "code": "97116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 26.6, "10th_percentile": 26.6, "90th_percentile": 53.2, "count": "13" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 26.6, "10th_percentile": 26.6, "90th_percentile": 53.2, "count": "13" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 26.6, "10th_percentile": 26.6, "90th_percentile": 53.2, "count": "13" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28, "10th_percentile": 28, "90th_percentile": 56, "count": "31" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.22, "10th_percentile": 31.22, "90th_percentile": 62.44, "count": "24" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28, "10th_percentile": 28, "90th_percentile": 56, "count": "119" } ], "minimum": 26.6, "maximum": 120 } ] }, { "description": "Pt eval low complex 20 min", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 95.34, "10th_percentile": 95.34, "90th_percentile": 95.34, "count": "1 through 10" } ], "minimum": 90.57, "maximum": 150 } ] }, { "description": "Pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 95.34, "10th_percentile": 95.34, "90th_percentile": 95.34, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 95.34, "10th_percentile": 95.34, "90th_percentile": 95.34, "count": "1 through 10" } ], "minimum": 95.34, "maximum": 150 } ] }, { "description": "Pt eval high complex 45 min", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 95.34, "10th_percentile": 95.34, "90th_percentile": 95.34, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 72.51, "10th_percentile": 72.51, "90th_percentile": 72.51, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 95.34, "10th_percentile": 95.34, "90th_percentile": 95.34, "count": "1 through 10" } ], "minimum": 72.51, "maximum": 150 } ] }, { "description": "Pt re-eval est plan care", "code_information": [ { "code": "97164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "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": "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 120, "maximum": 150 } ] }, { "description": "Ot eval low complex 30 min", "code_information": [ { "code": "97165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 92.9, "10th_percentile": 92.9, "90th_percentile": 92.9, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 92.9, "10th_percentile": 92.9, "90th_percentile": 92.9, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 92.9, "10th_percentile": 92.9, "90th_percentile": 92.9, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 97.79, "10th_percentile": 97.79, "90th_percentile": 97.79, "count": "1 through 10" } ], "minimum": 92.9, "maximum": 150 } ] }, { "description": "Ot eval mod complex 45 min", "code_information": [ { "code": "97166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 97.79, "10th_percentile": 97.79, "90th_percentile": 97.79, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 97.79, "10th_percentile": 97.79, "90th_percentile": 97.79, "count": "1 through 10" } ], "minimum": 97.79, "maximum": 150 } ] }, { "description": "Therapeutic activities", "code_information": [ { "code": "97530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 63.64, "10th_percentile": 31.82, "90th_percentile": 95.46, "count": "21" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 63.64, "10th_percentile": 31.82, "90th_percentile": 95.46, "count": "21" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 63.64, "10th_percentile": 31.82, "90th_percentile": 95.46, "count": "21" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 66.98, "10th_percentile": 33.49, "90th_percentile": 66.98, "count": "51" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.85, "10th_percentile": 26.85, "90th_percentile": 26.85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "52" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.49, "10th_percentile": 33.49, "90th_percentile": 66.98, "count": "105" } ], "minimum": 26.85, "maximum": 120 } ] }, { "description": "Self care mngment training", "code_information": [ { "code": "97535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 62.12, "10th_percentile": 62.12, "90th_percentile": 62.12, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.06, "10th_percentile": 31.06, "90th_percentile": 31.06, "count": "1 through 10" } ], "minimum": 31.06, "maximum": 120 } ] }, { "description": "Mod sed same phys/qhp 5/>yrs", "code_information": [ { "code": "99152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 special svc px/rprt", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "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 Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "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", "standard_charge_percentage": 50, "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", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) Program", "standard_charge_percentage": 50, "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": "Commercial", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "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": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "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 Select", "standard_charge_percentage": 100, "methodology": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators®", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "indemnity plans with network incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "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": "Aetna Network Services", "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": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HealthSelect", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "POS", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 mebrofenin", "code_information": [ { "code": "A9537", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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 ceftazidime per 500 mg", "code_information": [ { "code": "J0713", "type": "HCPCS" }, { "code": "00409-5082-16", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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 tbo filgrastim 1 microg", "code_information": [ { "code": "J1447", "type": "HCPCS" }, { "code": "63459-0918-59", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Fluconazole", "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "00338-6045-37", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Haloperidol injection", "code_information": [ { "code": "J1630", "type": "HCPCS" }, { "code": "00143-9319-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Furosemide injection", "code_information": [ { "code": "J1940", "type": "HCPCS" }, { "code": "00143-9155-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "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": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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, propofol, 10 mg", "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "00069-0209-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "J2920", "type": "HCPCS" }, { "code": "00143-9753-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Fentanyl citrate injection", "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "00406-1130-52", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": 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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "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": "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_percentage": 80, "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": 20, "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": "Automobile Insurance", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "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": "PPO", "standard_charge_percentage": 20, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Post chmbr intraocular lens", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=57.50- Tier Tier 2", "code_information": [ { "code": "C1701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=57.50- Tier Tier 3", "code_information": [ { "code": "D1701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=50.50 and M <57.50- Tier None", "code_information": [ { "code": "A1702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=50.50 and M <57.50- Tier Tier 1", "code_information": [ { "code": "B1702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=50.50 and M <57.50- Tier Tier 2", "code_information": [ { "code": "C1702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=50.50 and M <57.50- Tier Tier 3", "code_information": [ { "code": "D1702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=41.50 and M <50.50- Tier None", "code_information": [ { "code": "A1703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 23977.8, "10th_percentile": 23977.8, "90th_percentile": 24353.25, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23977.8, "maximum": 23977.8 } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=41.50 and M <50.50- Tier Tier 1", "code_information": [ { "code": "B1703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=41.50 and M <50.50- Tier Tier 2", "code_information": [ { "code": "C1703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=41.50 and M <50.50- Tier Tier 3", "code_information": [ { "code": "D1703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=36.50 and M <41.50- Tier None", "code_information": [ { "code": "A1704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare PPO", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage (Humana)", "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": "Coventry Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "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": 28023.49, "10th_percentile": 28023.49, "90th_percentile": 28023.49, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "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": "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": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28023.49, "maximum": 28023.49 } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=36.50 and M <41.50- Tier Tier 1", "code_information": [ { "code": "B1704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "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" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare POS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Network PFFS", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_no