{ "hospital_name": "Elkhorn Valley Rehabilitation Hospital", "last_updated_on": "2026-03-17", "version": "3.0.0", "location_name": [ "Elkhorn Valley Rehabilitation Hospital" ], "hospital_address": [ "5715 E 2nd St, Casper, WY 82609" ], "license_information": { "state": "WY" }, "type_2_npi": [ "1326233586" ], "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": "Laboratory - General Classification", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Chemistry", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - General Classification", "code_information": [ { "code": "0410", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Physical Therapy - General Classification", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Physical Therapy - Visit Charge", "code_information": [ { "code": "0421", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Physical Therapy - Evaluation or Re-evaluation", "code_information": [ { "code": "0424", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Occupational Therapy - General Classification", "code_information": [ { "code": "0430", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Occupational Therapy - Evaluation or Reevaluation", "code_information": [ { "code": "0434", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Speech Therapy - Language Pathology - General Classification", "code_information": [ { "code": "0440", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Speech Therapy - Language Pathology - Evaluation or Reevaluation", "code_information": [ { "code": "0444", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "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": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Therapeutic exercises", "code_information": [ { "code": "97110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 97.5, "10th_percentile": 48.75, "90th_percentile": 146.25, "count": "46" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 110.5, "10th_percentile": 55.25, "90th_percentile": 110.5, "count": "31" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28.7, "10th_percentile": 28.7, "90th_percentile": 28.7, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28.7, "maximum": 120 } ] }, { "description": "Therapeutic activities", "code_information": [ { "code": "97530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 97.5, "10th_percentile": 48.75, "90th_percentile": 146.25, "count": "26" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 55.25, "10th_percentile": 55.25, "90th_percentile": 110.5, "count": "34" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34.53, "10th_percentile": 34.53, "90th_percentile": 34.53, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34.53, "maximum": 120 } ] }, { "description": "Neuromuscular reeducation", "code_information": [ { "code": "97112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 97.5, "10th_percentile": 48.75, "90th_percentile": 97.5, "count": "40" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 110.5, "10th_percentile": 110.5, "90th_percentile": 165.75, "count": "16" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Gait training therapy", "code_information": [ { "code": "97116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 97.5, "10th_percentile": 48.75, "90th_percentile": 97.5, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 55.25, "10th_percentile": 55.25, "90th_percentile": 55.25, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 55.25, "maximum": 120 } ] }, { "description": "Speech/hearing therapy", "code_information": [ { "code": "92507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "count": "20" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 221, "10th_percentile": 221, "90th_percentile": 221, "count": "13" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 221 } ] }, { "description": "Manual therapy 1/> regions", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 97.5, "10th_percentile": 48.75, "90th_percentile": 195, "count": "34" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 55.25, "10th_percentile": 55.25, "90th_percentile": 165.75, "count": "15" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 55.25, "maximum": 120 } ] }, { "description": "Pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 221, "10th_percentile": 221, "90th_percentile": 221, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 221 } ] }, { "description": "Ther ivntj ea addl 15 min", "code_information": [ { "code": "97130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 146.25, "10th_percentile": 146.25, "90th_percentile": 146.25, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 165.75, "10th_percentile": 165.75, "90th_percentile": 165.75, "count": "30" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 165.75 } ] }, { "description": "Aquatic therapy/exercises", "code_information": [ { "code": "97113", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Oral function therapy", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Ot eval mod complex 45 min", "code_information": [ { "code": "97166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 221, "10th_percentile": 221, "90th_percentile": 221, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 221 } ] }, { "description": "Ther ivntj 1st 15 min", "code_information": [ { "code": "97129", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 48.75, "10th_percentile": 48.75, "90th_percentile": 48.75, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 55.25, "10th_percentile": 55.25, "90th_percentile": 55.25, "count": "30" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 48.75, "maximum": 120 } ] }, { "description": "Pt eval low complex 20 min", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 195 } ] }, { "description": "Hemodialysis one evaluation", "code_information": [ { "code": "90935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Self care mngment training", "code_information": [ { "code": "97535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Unlisted special svc px/rprt", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech sound lang comprehen", "code_information": [ { "code": "92523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Pt eval high complex 45 min", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 97.67, "10th_percentile": 97.67, "90th_percentile": 97.67, "count": "1 through 10" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 195 } ] }, { "description": "Evaluate swallowing function", "code_information": [ { "code": "92610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 70 } ] }, { "description": "Ot eval low complex 30 min", "code_information": [ { "code": "97165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 221, "10th_percentile": 221, "90th_percentile": 221, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 221 } ] }, { "description": "Cognitive test by hc pro", "code_information": [ { "code": "96125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 195, "10th_percentile": 195, "90th_percentile": 195, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 221, "10th_percentile": 221, "90th_percentile": 221, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 221 } ] }, { "description": "Appl modality 1+estim ea 15", "code_information": [ { "code": "97032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Ot eval high complex 60 min", "code_information": [ { "code": "97167", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Glucose other fluid", "code_information": [ { "code": "82945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavral qualit analys voice", "code_information": [ { "code": "92524", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 243.75, "10th_percentile": 243.75, "90th_percentile": 243.75, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 243.75 } ] }, { "description": "Debride nail 6 or more", "code_information": [ { "code": "11721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+ultrasound ea 15", "code_information": [ { "code": "97035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 48.75, "10th_percentile": 48.75, "90th_percentile": 48.75, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 48.75, "maximum": 70 } ] }, { "description": "Massage therapy", "code_information": [ { "code": "97124", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Glucose blood test", "code_information": [ { "code": "82962", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assessment of aphasia", "code_information": [ { "code": "96105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Physical performance test", "code_information": [ { "code": "97750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 70 } ] }, { "description": "X-ray exam chest 1 view", "code_information": [ { "code": "71045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Evaluate speech production", "code_information": [ { "code": "92522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Use of speech device service", "code_information": [ { "code": "92609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 70 } ] }, { "description": "Wheelchair mngment training", "code_information": [ { "code": "97542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Endoscopy swallow (fees) vid", "code_information": [ { "code": "92612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 70 } ] }, { "description": "Vent mgmt inpat subq day", "code_information": [ { "code": "94003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthotic mgmt&traing 1st enc", "code_information": [ { "code": "97760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 70 } ] }, { "description": "Ot re-eval est plan care", "code_information": [ { "code": "97168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Electric stimulation therapy", "code_information": [ { "code": "97014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthc/prostc mgmt sbsq enc", "code_information": [ { "code": "97763", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 70 } ] }, { "description": "Complete cbc w/auto diff wbc", "code_information": [ { "code": "85025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pt re-eval est plan care", "code_information": [ { "code": "97164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 150 } ] }, { "description": "Canalith repositioning proc", "code_information": [ { "code": "95992", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sensory integration", "code_information": [ { "code": "97533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 120, "maximum": 120 } ] }, { "description": "Community/work reintegration", "code_information": [ { "code": "97537", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 120 } ] }, { "description": "Metabolic panel total ca", "code_information": [ { "code": "80048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 3+ musc", "code_information": [ { "code": "20561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 1 or 2 musc", "code_information": [ { "code": "20560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+iontphrsis ea 15", "code_information": [ { "code": "97033", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Paraffin bath therapy", "code_information": [ { "code": "97018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct head/brain w/o & w/dye", "code_information": [ { "code": "70470", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam chest 2 views", "code_information": [ { "code": "71046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ex for speech device rx 1hr", "code_information": [ { "code": "92607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Vent mgmt inpat init day", "code_information": [ { "code": "94002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resp virus 12-25 targets", "code_information": [ { "code": "87633", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs moderate 35", "code_information": [ { "code": "99232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application of finger splint", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 97.5, "10th_percentile": 97.5, "90th_percentile": 97.5, "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": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 97.5, "maximum": 97.5 } ] }, { "description": "Prosthetic traing 1st enc", "code_information": [ { "code": "97761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mechanical traction therapy", "code_information": [ { "code": "97012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri lumbar spine w/o & w/dye", "code_information": [ { "code": "72158", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelv w/contrast", "code_information": [ { "code": "74177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted e&m service", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Caregiver traing 1st 30 min", "code_information": [ { "code": "97550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs sf/low 25", "code_information": [ { "code": "99231", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "C diff amplified probe", "code_information": [ { "code": "87493", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29126", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam abdom complete", "code_information": [ { "code": "76700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of pelvis", "code_information": [ { "code": "72170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knee 1 or 2", "code_information": [ { "code": "73560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam abdomen 1 view", "code_information": [ { "code": "74018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "1st hosp ip/obs high 75", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_percentage": 75, "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": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "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": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 None", "code_information": [ { "code": "A0102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 16552.54, "10th_percentile": 16552.54, "90th_percentile": 16552.54, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16552.54, "maximum": 16552.54 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 18762.56, "10th_percentile": 18762.56, "90th_percentile": 18762.56, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18762.56, "maximum": 18762.56 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 21333.25, "10th_percentile": 21333.25, "90th_percentile": 21333.25, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21333.25, "maximum": 21333.25 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24085.66, "10th_percentile": 22386.41, "90th_percentile": 24085.66, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 24085.66, "10th_percentile": 24085.66, "90th_percentile": 24085.66, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24085.66, "maximum": 24085.66 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27227.1, "10th_percentile": 27227.1, "90th_percentile": 29179.47, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 29179.47, "10th_percentile": 29179.47, "90th_percentile": 29179.47, "count": "1 through 10" } ], "minimum": 27227.1, "maximum": 29179.47 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31263.36, "10th_percentile": 31263.36, "90th_percentile": 31263.36, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31263.36, "maximum": 31263.36 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 28569.58, "10th_percentile": 28569.58, "90th_percentile": 28569.58, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 28569.58, "10th_percentile": 28569.58, "90th_percentile": 30763.7, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28569.58, "maximum": 28569.58 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 34047.11, "10th_percentile": 34047.11, "90th_percentile": 36365.37, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34047.11, "maximum": 34047.11 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 35724.76, "10th_percentile": 4465.6, "90th_percentile": 38338.09, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 35724.76, "maximum": 35724.76 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 38723.73, "10th_percentile": 38723.73, "90th_percentile": 40962.69, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 38723.73, "10th_percentile": 38723.73, "90th_percentile": 38723.73, "count": "1 through 10" } ], "minimum": 38723.73, "maximum": 38723.73 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 51271.77, "10th_percentile": 51271.77, "90th_percentile": 51271.77, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 51271.77, "maximum": 51271.77 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 40634.25, "10th_percentile": 40634.25, "90th_percentile": 40634.25, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 40634.25, "10th_percentile": 40634.25, "90th_percentile": 43185.54, "count": "24" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 40634.25, "maximum": 40634.25 } ] }, { "description": "Traumatic brain injury M >=73.50- Tier None", "code_information": [ { "code": "A0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22287.29, "10th_percentile": 22287.29, "90th_percentile": 22287.29, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22287.29, "maximum": 22287.29 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 3", "code_information": [ { "code": "D0203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 21917.16, "10th_percentile": 21917.16, "90th_percentile": 23721.82, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21917.16, "maximum": 21917.16 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25593.54, "10th_percentile": 25593.54, "90th_percentile": 25593.54, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25593.54, "maximum": 25593.54 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 >=35.50 and M <49.50- Tier Tier 2", "code_information": [ { "code": "C0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29929.7, "10th_percentile": 29929.7, "90th_percentile": 29929.7, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29929.7, "maximum": 29929.7 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27183, "10th_percentile": 27183, "90th_percentile": 29236.32, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27183, "maximum": 27183 } ] }, { "description": "Traumatic brain injury M <35.50- Tier None", "code_information": [ { "code": "A0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 32782.25, "10th_percentile": 32782.25, "90th_percentile": 32782.25, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32782.25, "maximum": 32782.25 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 1", "code_information": [ { "code": "B0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 <35.50- Tier Tier 2", "code_information": [ { "code": "C0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 38335.63, "10th_percentile": 38335.63, "90th_percentile": 38335.63, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 38335.63, "maximum": 38335.63 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 3", "code_information": [ { "code": "D0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 34819.78, "10th_percentile": 34819.78, "90th_percentile": 34819.78, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34819.78, "maximum": 34819.78 } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier None", "code_information": [ { "code": "A0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 21146.25, "10th_percentile": 21146.25, "90th_percentile": 21146.25, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21146.25, "maximum": 21146.25 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 1", "code_information": [ { "code": "B0302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 21874.82, "10th_percentile": 21874.82, "90th_percentile": 21874.82, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21874.82, "maximum": 21874.82 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 20093.08, "10th_percentile": 20093.08, "90th_percentile": 20093.08, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20093.08, "maximum": 20093.08 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22786.86, "10th_percentile": 22786.86, "90th_percentile": 23939.75, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22786.86, "maximum": 22786.86 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 M <52.50- Tier Tier 2", "code_information": [ { "code": "C0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26318.59, "10th_percentile": 26318.59, "90th_percentile": 26318.59, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26318.59, "maximum": 26318.59 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24176.97, "10th_percentile": 24176.97, "90th_percentile": 24176.97, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 24176.97, "10th_percentile": 24176.97, "90th_percentile": 25571.36, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24176.97, "maximum": 24176.97 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26420.91, "10th_percentile": 26420.91, "90th_percentile": 26420.91, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26420.91, "maximum": 26420.91 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30515.38, "10th_percentile": 30515.38, "90th_percentile": 30515.38, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30515.38, "maximum": 30515.38 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 28031.53, "10th_percentile": 28031.53, "90th_percentile": 30291.84, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28031.53, "maximum": 28031.53 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 1", "code_information": [ { "code": "B0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 33653.71, "10th_percentile": 33653.71, "90th_percentile": 33653.71, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 33653.71, "maximum": 33653.71 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 30914.07, "10th_percentile": 30914.07, "90th_percentile": 30914.07, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30914.07, "10th_percentile": 30914.07, "90th_percentile": 33183.64, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30914.07, "maximum": 30914.07 } ] }, { "description": "Traumatic spinal cord injury M >=56.50- Tier None", "code_information": [ { "code": "A0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 1", "code_information": [ { "code": "B0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 3", "code_information": [ { "code": "D0404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 1", "code_information": [ { "code": "B0405", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 70210.38, "10th_percentile": 70210.38, "90th_percentile": 70210.38, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70210.38, "maximum": 70210.38 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 19032.86, "10th_percentile": 19032.86, "90th_percentile": 19032.86, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19032.86, "maximum": 19032.86 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 1", "code_information": [ { "code": "B0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29790.34, "10th_percentile": 29790.34, "90th_percentile": 29790.34, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29790.34, "maximum": 29790.34 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 29789.67, "10th_percentile": 29789.67, "90th_percentile": 29789.67, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 28144.43, "10th_percentile": 28144.43, "90th_percentile": 28144.43, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28144.43, "maximum": 29789.67 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 2702.91, "10th_percentile": 2702.91, "90th_percentile": 36038.77, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 2702.91, "maximum": 2702.91 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 Tier 2", "code_information": [ { "code": "C0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 41396.34, "10th_percentile": 41396.34, "90th_percentile": 41396.34, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 41396.34, "maximum": 41396.34 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 42327.1, "10th_percentile": 42327.1, "90th_percentile": 42327.1, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 42327.1, "maximum": 42327.1 } ] }, { "description": "Neurological M >=64.50- Tier None", "code_information": [ { "code": "A0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 16383.18, "10th_percentile": 16383.18, "90th_percentile": 16383.18, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16383.18, "maximum": 16383.18 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 18740.02, "10th_percentile": 18740.02, "90th_percentile": 18740.02, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 18740.02, "10th_percentile": 18740.02, "90th_percentile": 18740.02, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18740.02, "maximum": 18740.02 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 20779.32, "10th_percentile": 20779.32, "90th_percentile": 22018.2, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20779.32, "maximum": 20779.32 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22081.22, "10th_percentile": 22081.22, "90th_percentile": 22081.22, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22081.22, "maximum": 22081.22 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 26226.86, "10th_percentile": 26226.86, "90th_percentile": 27799.9, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26226.86, "10th_percentile": 26226.86, "90th_percentile": 26226.86, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26226.86, "maximum": 26226.86 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24483.93, "10th_percentile": 24483.93, "90th_percentile": 24483.93, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 24483.93, "10th_percentile": 24483.93, "90th_percentile": 24483.93, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24483.93, "maximum": 24483.93 } ] }, { "description": "Neurological M <43.50- Tier None", "code_information": [ { "code": "A0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29744.19, "10th_percentile": 27692.82, "90th_percentile": 29744.19, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29744.19, "maximum": 29744.19 } ] }, { "description": "Neurological M <43.50- Tier Tier 1", "code_information": [ { "code": "B0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Neurological M <43.50- Tier Tier 2", "code_information": [ { "code": "C0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 32891.62, "10th_percentile": 32891.62, "90th_percentile": 32891.62, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32891.62, "maximum": 32891.62 } ] }, { "description": "Neurological M <43.50- Tier Tier 3", "code_information": [ { "code": "D0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30705.9, "10th_percentile": 30705.9, "90th_percentile": 33115.42, "count": "13" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30705.9, "maximum": 30705.9 } ] }, { "description": "Fracture of lower extremity M >=61.50- Tier None", "code_information": [ { "code": "A0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 18501.87, "10th_percentile": 18501.87, "90th_percentile": 19941.26, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18501.87, "maximum": 18501.87 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 3", "code_information": [ { "code": "D0702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 20026.05, "10th_percentile": 20026.05, "90th_percentile": 20026.05, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20026.05, "maximum": 20026.05 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 5688.34, "10th_percentile": 5688.34, "90th_percentile": 24430.56, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22753.35, "10th_percentile": 22753.35, "90th_percentile": 24430.56, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 5688.34, "maximum": 22753.35 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 3", "code_information": [ { "code": "D0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24626.82, "10th_percentile": 24626.82, "90th_percentile": 24626.82, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 24626.82, "10th_percentile": 24626.82, "90th_percentile": 26734.9, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24626.82, "maximum": 24626.82 } ] }, { "description": "Fracture of lower extremity M <41.50- Tier None", "code_information": [ { "code": "A0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27795.14, "10th_percentile": 27795.14, "90th_percentile": 27795.14, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27795.14, "10th_percentile": 27795.14, "90th_percentile": 30164.88, "count": "22" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27795.14, "maximum": 27795.14 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 43471.69, "10th_percentile": 43471.69, "90th_percentile": 43471.69, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 43471.69, "maximum": 43471.69 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31759.07, "10th_percentile": 31759.07, "90th_percentile": 31759.07, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31759.07, "10th_percentile": 31759.07, "90th_percentile": 31759.07, "count": "1 through 10" } ], "minimum": 31759.07, "maximum": 31759.07 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 30084.94, "10th_percentile": 30084.94, "90th_percentile": 30084.94, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30084.94, "10th_percentile": 30084.94, "90th_percentile": 33011.19, "count": "41" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 32179.32, "10th_percentile": 32179.32, "90th_percentile": 32179.32, "count": "1 through 10" } ], "minimum": 30084.94, "maximum": 32179.32 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 1", "code_information": [ { "code": "B0802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 17787.41, "10th_percentile": 17787.41, "90th_percentile": 17787.41, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17787.41, "maximum": 17787.41 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 18466.59, "10th_percentile": 18466.59, "90th_percentile": 18466.59, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18466.59, "maximum": 18466.59 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 19798.48, "10th_percentile": 19798.48, "90th_percentile": 19798.48, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19798.48, "maximum": 19798.48 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 20687.59, "10th_percentile": 20687.59, "90th_percentile": 20687.59, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 20687.59, "10th_percentile": 20687.59, "90th_percentile": 20687.59, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20687.59, "maximum": 20687.59 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 22181.78, "10th_percentile": 22181.78, "90th_percentile": 22181.78, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22181.78, "10th_percentile": 22181.78, "90th_percentile": 23951.12, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22181.78, "maximum": 22181.78 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27949.6, "10th_percentile": 2658.43, "90th_percentile": 27949.6, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27949.6, "maximum": 27949.6 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 3", "code_information": [ { "code": "D0805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26602.61, "10th_percentile": 26602.61, "90th_percentile": 29831.36, "count": "18" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26602.61, "maximum": 26602.61 } ] }, { "description": "Other orthopedic M >=63.50- Tier None", "code_information": [ { "code": "A0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 18034.38, "10th_percentile": 18034.38, "90th_percentile": 18034.38, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18034.38, "maximum": 18034.38 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 3", "code_information": [ { "code": "D0902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 19710.28, "10th_percentile": 19710.28, "90th_percentile": 21332.21, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19710.28, "maximum": 19710.28 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 21536.12, "10th_percentile": 21536.12, "90th_percentile": 21536.12, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21536.12, "maximum": 21536.12 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25253.07, "10th_percentile": 25253.07, "90th_percentile": 25253.07, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25253.07, "maximum": 25253.07 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 23538.37, "10th_percentile": 23538.37, "90th_percentile": 23538.37, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 23538.37, "10th_percentile": 23538.37, "90th_percentile": 25313.64, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23538.37, "maximum": 23538.37 } ] }, { "description": "Other orthopedic M <44.5- Tier None", "code_information": [ { "code": "A0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25805.24, "10th_percentile": 2580.52, "90th_percentile": 27809.37, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25805.24, "maximum": 25805.24 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 1", "code_information": [ { "code": "B0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 37779.94, "10th_percentile": 37779.94, "90th_percentile": 37779.94, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 37779.94, "maximum": 37779.94 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 2", "code_information": [ { "code": "C0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30259.59, "10th_percentile": 30259.59, "90th_percentile": 30259.59, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30259.59, "maximum": 30259.59 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 3", "code_information": [ { "code": "D0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 28204.41, "10th_percentile": 28204.41, "90th_percentile": 30483.24, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 28204.41, "10th_percentile": 28204.41, "90th_percentile": 30483.24, "count": "33" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28204.41, "10th_percentile": 28204.41, "90th_percentile": 28204.41, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28204.41, "10th_percentile": 28204.41, "90th_percentile": 28204.41, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28204.41, "maximum": 28204.41 } ] }, { "description": "Amputation lower extremity M >=64.50- Tier None", "code_information": [ { "code": "A1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 21462.03, "10th_percentile": 21462.03, "90th_percentile": 21462.03, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21462.03, "maximum": 21462.03 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 23954.7, "10th_percentile": 23954.7, "90th_percentile": 23954.7, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 23954.7, "10th_percentile": 23954.7, "90th_percentile": 23954.7, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23954.7, "maximum": 23954.7 } ] }, { "description": "Amputation lower extremity M <47.50- Tier None", "code_information": [ { "code": "A1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27475.84, "10th_percentile": 27475.84, "90th_percentile": 31362.53, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27475.84, "maximum": 27475.84 } ] }, { "description": "Amputation lower extremity M <47.50- Tier Tier 1", "code_information": [ { "code": "B1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 Tier 2", "code_information": [ { "code": "C1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 Tier 3", "code_information": [ { "code": "D1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 6954.04, "10th_percentile": 6954.04, "90th_percentile": 6954.04, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30667.09, "10th_percentile": 30667.09, "90th_percentile": 33776.78, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33776.78, "10th_percentile": 33776.78, "90th_percentile": 33776.78, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33776.78, "10th_percentile": 33776.78, "90th_percentile": 33776.78, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33776.78, "10th_percentile": 33776.78, "90th_percentile": 33776.78, "count": "1 through 10" } ], "minimum": 6954.04, "maximum": 33776.78 } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier None", "code_information": [ { "code": "A1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=49.50 and M <61.50- Tier None", "code_information": [ { "code": "A1202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=49.50 and M <61.50- Tier Tier 1", "code_information": [ { "code": "B1202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=49.50 and M <61.50- Tier Tier 2", "code_information": [ { "code": "C1202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M >=49.50 and M <61.50- Tier Tier 3", "code_information": [ { "code": "D1202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M <49.50 and A >=74.50- Tier None", "code_information": [ { "code": "A1203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 23938.82, "10th_percentile": 23938.82, "90th_percentile": 23938.82, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23938.82, "maximum": 23938.82 } ] }, { "description": "Osteoarthritis M <49.50 and A >=74.50- Tier Tier 1", "code_information": [ { "code": "B1203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M <49.50 and A >=74.50- Tier Tier 2", "code_information": [ { "code": "C1203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M <49.50 and A >=74.50- Tier Tier 3", "code_information": [ { "code": "D1203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26186.28, "10th_percentile": 26186.28, "90th_percentile": 26186.28, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26186.28, "maximum": 26186.28 } ] }, { "description": "Osteoarthritis M <49.50 and A <74.50- Tier None", "code_information": [ { "code": "A1204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M <49.50 and A <74.50- Tier Tier 1", "code_information": [ { "code": "B1204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M <49.50 and A <74.50- Tier Tier 2", "code_information": [ { "code": "C1204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteoarthritis M <49.50 and A <74.50- Tier Tier 3", "code_information": [ { "code": "D1204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=62.50- Tier None", "code_information": [ { "code": "A1301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=62.50- Tier Tier 1", "code_information": [ { "code": "B1301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=62.50- Tier Tier 2", "code_information": [ { "code": "C1301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=62.50- Tier Tier 3", "code_information": [ { "code": "D1301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=51.50 and M <62.50- Tier None", "code_information": [ { "code": "A1302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=51.50 and M <62.50- Tier Tier 1", "code_information": [ { "code": "B1302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=51.50 and M <62.50- Tier Tier 2", "code_information": [ { "code": "C1302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=51.50 and M <62.50- Tier Tier 3", "code_information": [ { "code": "D1302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=44.50 and M <51.50 and A >=64.50- Tier None", "code_information": [ { "code": "A1303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=44.50 and M <51.50 and A >=64.50- Tier Tier 1", "code_information": [ { "code": "B1303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=44.50 and M <51.50 and A >=64.50- Tier Tier 2", "code_information": [ { "code": "C1303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M >=44.50 and M <51.50 and A >=64.50- Tier Tier 3", "code_information": [ { "code": "D1303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M <44.50 and A >=64.50- Tier None", "code_information": [ { "code": "A1304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M <44.50 and A >=64.50- Tier Tier 1", "code_information": [ { "code": "B1304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M <44.50 and A >=64.50- Tier Tier 2", "code_information": [ { "code": "C1304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31236.9, "10th_percentile": 31236.9, "90th_percentile": 31236.9, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31236.9, "maximum": 31236.9 } ] }, { "description": "Rheumatoid other arthritis M <44.50 and A >=64.50- Tier Tier 3", "code_information": [ { "code": "D1304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29816.8, "10th_percentile": 29816.8, "90th_percentile": 29816.8, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29816.8, "maximum": 29816.8 } ] }, { "description": "Rheumatoid other arthritis M <51.50 and A <64.50- Tier None", "code_information": [ { "code": "A1305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M <51.50 and A <64.50- Tier Tier 1", "code_information": [ { "code": "B1305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M <51.50 and A <64.50- Tier Tier 2", "code_information": [ { "code": "C1305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rheumatoid other arthritis M <51.50 and A <64.50- Tier Tier 3", "code_information": [ { "code": "D1305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=68.50- Tier None", "code_information": [ { "code": "A1401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=68.50- Tier Tier 1", "code_information": [ { "code": "B1401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=68.50- Tier Tier 2", "code_information": [ { "code": "C1401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 15682.84, "10th_percentile": 15682.84, "90th_percentile": 15682.84, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 15682.84, "maximum": 15682.84 } ] }, { "description": "Cardiac M >=68.50- Tier Tier 3", "code_information": [ { "code": "D1401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=55.50 and M <68.50- Tier None", "code_information": [ { "code": "A1402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 17016.5, "10th_percentile": 17016.5, "90th_percentile": 17016.5, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17016.5, "maximum": 17016.5 } ] }, { "description": "Cardiac M >=55.50 and M <68.50- Tier Tier 1", "code_information": [ { "code": "B1402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=55.50 and M <68.50- Tier Tier 2", "code_information": [ { "code": "C1402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=55.50 and M <68.50- Tier Tier 3", "code_information": [ { "code": "D1402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 20092.86, "10th_percentile": 20092.86, "90th_percentile": 20092.86, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 18493.05, "10th_percentile": 18493.05, "90th_percentile": 18493.05, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18493.05, "maximum": 20092.86 } ] }, { "description": "Cardiac M >=45.50 and M <55.50- Tier None", "code_information": [ { "code": "A1403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=45.50 and M <55.50- Tier Tier 1", "code_information": [ { "code": "B1403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=45.50 and M <55.50- Tier Tier 2", "code_information": [ { "code": "C1403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M >=45.50 and M <55.50- Tier Tier 3", "code_information": [ { "code": "D1403", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 22628.09, "10th_percentile": 22628.09, "90th_percentile": 22628.09, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22628.09, "10th_percentile": 22628.09, "90th_percentile": 24286.54, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22628.09, "maximum": 22628.09 } ] }, { "description": "Cardiac M <45.50- Tier None", "code_information": [ { "code": "A1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25512.4, "10th_percentile": 25512.4, "90th_percentile": 25512.4, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25512.4, "maximum": 25512.4 } ] }, { "description": "Cardiac M <45.50- Tier Tier 1", "code_information": [ { "code": "B1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac M <45.50- Tier Tier 2", "code_information": [ { "code": "C1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29820.32, "10th_percentile": 29820.32, "90th_percentile": 32772.42, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29820.32, "maximum": 29820.32 } ] }, { "description": "Cardiac M <45.50- Tier Tier 3", "code_information": [ { "code": "D1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27726.34, "10th_percentile": 27726.34, "90th_percentile": 30303.22, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27726.34, "maximum": 27726.34 } ] }, { "description": "Pulmonary M >=68.50- Tier None", "code_information": [ { "code": "A1501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary M >=68.50- Tier Tier 1", "code_information": [ { "code": "B1501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary M >=68.50- Tier Tier 2", "code_information": [ { "code": "C1501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary M >=68.50- Tier Tier 3", "code_information": [ { "code": "D1501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 None", "code_information": [ { "code": "A1502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 23134.39, "10th_percentile": 23134.39, "90th_percentile": 23134.39, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23134.39, "maximum": 23134.39 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 28648.96, "10th_percentile": 28648.96, "90th_percentile": 28648.96, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28648.96, "maximum": 28648.96 } ] }, { "description": "Pulmonary M <45.50- Tier Tier 1", "code_information": [ { "code": "B1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 32565.26, "10th_percentile": 32565.26, "90th_percentile": 32565.26, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32565.26, "maximum": 32565.26 } ] }, { "description": "Pulmonary M <45.50- Tier Tier 3", "code_information": [ { "code": "D1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30626.52, "10th_percentile": 30626.52, "90th_percentile": 30626.52, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30626.52, "maximum": 30626.52 } ] }, { "description": "Pain syndrome M >=65.50- Tier None", "code_information": [ { "code": "A1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 None", "code_information": [ { "code": "A1604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 16981.21, "10th_percentile": 16981.21, "90th_percentile": 16981.21, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16981.21, "maximum": 16981.21 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 22744.52, "10th_percentile": 22744.52, "90th_percentile": 24481.72, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22744.52, "maximum": 22744.52 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25069.61, "10th_percentile": 25069.61, "90th_percentile": 26592.77, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25069.61, "maximum": 25069.61 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25741.73, "10th_percentile": 25741.73, "90th_percentile": 25741.73, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25741.73, "maximum": 25741.73 } ] }, { "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": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 Tier 2", "code_information": [ { "code": "C1704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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 Tier 3", "code_information": [ { "code": "D1704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 28373.76, "10th_percentile": 28373.76, "90th_percentile": 28373.76, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28373.76, "maximum": 28373.76 } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M <36.50- Tier None", "code_information": [ { "code": "A1705", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 30208.43, "10th_percentile": 30208.43, "90th_percentile": 32795.16, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30208.43, "maximum": 30208.43 } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M <36.50- Tier Tier 1", "code_information": [ { "code": "B1705", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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- Tier Tier 2", "code_information": [ { "code": "C1705", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 35954.1, "10th_percentile": 35954.1, "90th_percentile": 38368.41, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 35954.1, "maximum": 35954.1 } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M <36.50- Tier Tier 3", "code_information": [ { "code": "D1705", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 33297.36, "10th_percentile": 33297.36, "90th_percentile": 33297.36, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 33297.36, "10th_percentile": 6926.97, "90th_percentile": 35624.42, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 33297.36, "maximum": 33297.36 } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=67.50- Tier None", "code_information": [ { "code": "A1801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=67.50- Tier Tier 1", "code_information": [ { "code": "B1801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=67.50- Tier Tier 2", "code_information": [ { "code": "C1801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=67.50- Tier Tier 3", "code_information": [ { "code": "D1801", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=55.50 and M <67.50- Tier None", "code_information": [ { "code": "A1802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=55.50 and M <67.50- Tier Tier 1", "code_information": [ { "code": "B1802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=55.50 and M <67.50- Tier Tier 2", "code_information": [ { "code": "C1802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=55.50 and M <67.50- Tier Tier 3", "code_information": [ { "code": "D1802", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=45.50 and M <55.50- Tier None", "code_information": [ { "code": "A1803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=45.50 and M <55.50- Tier Tier 1", "code_information": [ { "code": "B1803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=45.50 and M <55.50- Tier Tier 2", "code_information": [ { "code": "C1803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=45.50 and M <55.50- Tier Tier 3", "code_information": [ { "code": "D1803", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=40.50 and M <45.50- Tier None", "code_information": [ { "code": "A1804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=40.50 and M <45.50- Tier Tier 1", "code_information": [ { "code": "B1804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=40.50 and M <45.50- Tier Tier 2", "code_information": [ { "code": "C1804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=40.50 and M <45.50- Tier Tier 3", "code_information": [ { "code": "D1804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26701.4, "10th_percentile": 26701.4, "90th_percentile": 29471.3, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26701.4, "maximum": 26701.4 } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=30.50 and M <40.50- Tier None", "code_information": [ { "code": "A1805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 33185.54, "10th_percentile": 30016.14, "90th_percentile": 33185.54, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 33185.54, "maximum": 33185.54 } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=30.50 and M <40.50- Tier Tier 1", "code_information": [ { "code": "B1805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=30.50 and M <40.50- Tier Tier 2", "code_information": [ { "code": "C1805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M >=30.50 and M <40.50- Tier Tier 3", "code_information": [ { "code": "D1805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 35357.23, "10th_percentile": 35357.23, "90th_percentile": 35357.23, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 35357.23, "maximum": 35357.23 } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M <30.50- Tier None", "code_information": [ { "code": "A1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 42627.68, "10th_percentile": 42627.68, "90th_percentile": 42627.68, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 42627.68, "maximum": 42627.68 } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M <30.50- Tier Tier 1", "code_information": [ { "code": "B1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M <30.50- Tier Tier 2", "code_information": [ { "code": "C1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 48428.04, "10th_percentile": 48428.04, "90th_percentile": 48428.04, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 48428.04, "maximum": 48428.04 } ] }, { "description": "Major multiple trauma with brain or spinal cord injury M <30.50- Tier Tier 3", "code_information": [ { "code": "D1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 51226.1, "10th_percentile": 45975.94, "90th_percentile": 51226.1, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 45975.94, "10th_percentile": 45975.94, "90th_percentile": 45975.94, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 45975.94, "maximum": 51226.1 } ] }, { "description": "Guillain-Barré M >=66.50- Tier None", "code_information": [ { "code": "A1901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=66.50- Tier Tier 1", "code_information": [ { "code": "B1901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=66.50- Tier Tier 2", "code_information": [ { "code": "C1901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=66.50- Tier Tier 3", "code_information": [ { "code": "D1901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=51.50 and M <66.50- Tier None", "code_information": [ { "code": "A1902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=51.50 and M <66.50- Tier Tier 1", "code_information": [ { "code": "B1902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=51.50 and M <66.50- Tier Tier 2", "code_information": [ { "code": "C1902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=51.50 and M <66.50- Tier Tier 3", "code_information": [ { "code": "D1902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=38.50 and M <51.50- Tier None", "code_information": [ { "code": "A1903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=38.50 and M <51.50- Tier Tier 1", "code_information": [ { "code": "B1903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=38.50 and M <51.50- Tier Tier 2", "code_information": [ { "code": "C1903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M >=38.50 and M <51.50- Tier Tier 3", "code_information": [ { "code": "D1903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31782, "10th_percentile": 31782, "90th_percentile": 31782, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31782, "maximum": 31782 } ] }, { "description": "Guillain-Barré M <38.50- Tier None", "code_information": [ { "code": "A1904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M <38.50- Tier Tier 1", "code_information": [ { "code": "B1904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M <38.50- Tier Tier 2", "code_information": [ { "code": "C1904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guillain-Barré M <38.50- Tier Tier 3", "code_information": [ { "code": "D1904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M >=66.50- Tier None", "code_information": [ { "code": "A2001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M >=66.50- Tier Tier 1", "code_information": [ { "code": "B2001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M >=66.50- Tier Tier 2", "code_information": [ { "code": "C2001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M >=66.50- Tier Tier 3", "code_information": [ { "code": "D2001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M >=55.50 and M <66.50- Tier None", "code_information": [ { "code": "A2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 17633.93, "10th_percentile": 17633.93, "90th_percentile": 17633.93, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17633.93, "maximum": 17633.93 } ] }, { "description": "Miscellaneous M >=55.50 and M <66.50- Tier Tier 1", "code_information": [ { "code": "B2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M >=55.50 and M <66.50- Tier Tier 2", "code_information": [ { "code": "C2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 20738.74, "10th_percentile": 20738.74, "90th_percentile": 20738.74, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20738.74, "maximum": 20738.74 } ] }, { "description": "Miscellaneous M >=55.50 and M <66.50- Tier Tier 3", "code_information": [ { "code": "D2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 19373.33, "10th_percentile": 19373.33, "90th_percentile": 19373.33, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 19373.33, "10th_percentile": 19373.33, "90th_percentile": 19373.33, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19373.33, "maximum": 19373.33 } ] }, { "description": "Miscellaneous M >=46.50 and M <55.50- Tier None", "code_information": [ { "code": "A2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 21116.26, "10th_percentile": 21116.26, "90th_percentile": 21116.26, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 21116.26, "10th_percentile": 21116.26, "90th_percentile": 21116.26, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21116.26, "maximum": 21116.26 } ] }, { "description": "Miscellaneous M >=46.50 and M <55.50- Tier Tier 1", "code_information": [ { "code": "B2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31092.24, "10th_percentile": 31092.24, "90th_percentile": 31092.24, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31092.24, "maximum": 31092.24 } ] }, { "description": "Miscellaneous M >=46.50 and M <55.50- Tier Tier 2", "code_information": [ { "code": "C2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 24834.98, "10th_percentile": 24834.98, "90th_percentile": 26331.26, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24834.98, "maximum": 24834.98 } ] }, { "description": "Miscellaneous M >=46.50 and M <55.50- Tier Tier 3", "code_information": [ { "code": "D2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 23199.66, "10th_percentile": 23199.66, "90th_percentile": 24487.41, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 23199.66, "10th_percentile": 23199.66, "90th_percentile": 24487.41, "count": "15" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23199.66, "10th_percentile": 23199.66, "90th_percentile": 23199.66, "count": "1 through 10" } ], "minimum": 23199.66, "maximum": 23199.66 } ] }, { "description": "Miscellaneous M <46.50 and A >=77.50- Tier None", "code_information": [ { "code": "A2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 25247.78, "10th_percentile": 5891.15, "90th_percentile": 27339.41, "count": "19" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25247.78, "maximum": 25247.78 } ] }, { "description": "Miscellaneous M <46.50 and A >=77.50- Tier Tier 1", "code_information": [ { "code": "B2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous M <46.50 and A >=77.50- Tier Tier 2", "code_information": [ { "code": "C2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29693.31, "10th_percentile": 29693.31, "90th_percentile": 32112.96, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29693.31, "maximum": 29693.31 } ] }, { "description": "Miscellaneous M <46.50 and A >=77.50- Tier Tier 3", "code_information": [ { "code": "D2004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27738.69, "10th_percentile": 27738.69, "90th_percentile": 29865.47, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 27738.69, "10th_percentile": 27738.69, "90th_percentile": 29865.47, "count": "26" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27738.69, "maximum": 27738.69 } ] }, { "description": "Miscellaneous M <46.50 and A <77.50- Tier None", "code_information": [ { "code": "A2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 26613.19, "10th_percentile": 26613.19, "90th_percentile": 28616.65, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26613.19, "maximum": 26613.19 } ] }, { "description": "Miscellaneous M <46.50 and A <77.50- Tier Tier 1", "code_information": [ { "code": "B2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 39184.16, "10th_percentile": 39184.16, "90th_percentile": 39184.16, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 39184.16, "maximum": 39184.16 } ] }, { "description": "Miscellaneous M <46.50 and A <77.50- Tier Tier 2", "code_information": [ { "code": "C2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31298.64, "10th_percentile": 31298.64, "90th_percentile": 33613.81, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31298.64, "maximum": 31298.64 } ] }, { "description": "Miscellaneous M <46.50 and A <77.50- Tier Tier 3", "code_information": [ { "code": "D2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 29238.17, "10th_percentile": 29238.17, "90th_percentile": 31260.2, "count": "24" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29238.17, "maximum": 29238.17 } ] }, { "description": "Burns M >=52.50- Tier None", "code_information": [ { "code": "A2101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M >=52.50- Tier Tier 1", "code_information": [ { "code": "B2101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M >=52.50- Tier Tier 2", "code_information": [ { "code": "C2101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M >=52.50- Tier Tier 3", "code_information": [ { "code": "D2101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M <52.50- Tier None", "code_information": [ { "code": "A2102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M <52.50- Tier Tier 1", "code_information": [ { "code": "B2102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M <52.50- Tier Tier 2", "code_information": [ { "code": "C2102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Burns M <52.50- Tier Tier 3", "code_information": [ { "code": "D2102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "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": 31067.54, "10th_percentile": 31067.54, "90th_percentile": 31067.54, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31067.54, "maximum": 31067.54 } ] }, { "description": "Short-stay cases, length of stay is 3 days or fewer- Tier None", "code_information": [ { "code": "A5001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Short-stay cases, length of stay is 3 days or fewer- Tier Tier 1", "code_information": [ { "code": "B5001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Short-stay cases, length of stay is 3 days or fewer- Tier Tier 2", "code_information": [ { "code": "C5001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Short-stay cases, length of stay is 3 days or fewer- Tier Tier 3", "code_information": [ { "code": "D5001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 13 days or fewer- Tier None", "code_information": [ { "code": "A5101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 13 days or fewer- Tier Tier 1", "code_information": [ { "code": "B5101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 13 days or fewer- Tier Tier 2", "code_information": [ { "code": "C5101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 13 days or fewer- Tier Tier 3", "code_information": [ { "code": "D5101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INJECTION, ADALIMUMAB, 20 MG", "code_information": [ { "code": "J0135", "type": "HCPCS" }, { "code": "00074-0124-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Inj ivig privigen 500 mg", "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0436-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Gamunex-c/gammaked", "code_information": [ { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-12", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Octagam injection", "code_information": [ { "code": "J1568", "type": "HCPCS" }, { "code": "00069-6002-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Romiplostim injection", "code_information": [ { "code": "J2796", "type": "HCPCS" }, { "code": "55513-0221-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Expired, orthopedic, length of stay is 14 days or more- Tier None", "code_information": [ { "code": "A5102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 14 days or more- Tier Tier 1", "code_information": [ { "code": "B5102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 14 days or more- Tier Tier 2", "code_information": [ { "code": "C5102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, orthopedic, length of stay is 14 days or more- Tier Tier 3", "code_information": [ { "code": "D5102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 15 days or fewer- Tier None", "code_information": [ { "code": "A5103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 15 days or fewer- Tier Tier 1", "code_information": [ { "code": "B5103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 15 days or fewer- Tier Tier 2", "code_information": [ { "code": "C5103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 15 days or fewer- Tier Tier 3", "code_information": [ { "code": "D5103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 16 days or more- Tier None", "code_information": [ { "code": "A5104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 16 days or more- Tier Tier 1", "code_information": [ { "code": "B5104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 16 days or more- Tier Tier 2", "code_information": [ { "code": "C5104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Expired, not orthopedic, length of stay is 16 days or more- Tier Tier 3", "code_information": [ { "code": "D5104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "standard_charge_percentage": 98, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inpatient Renal Dialysis - General Classification", "code_information": [ { "code": "0800", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Hemodialysis", "code_information": [ { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Peritoneal Dialysis (Non-CAPD)", "code_information": [ { "code": "0802", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Ambulatory Peritoneal Dialysis (CAPD)", "code_information": [ { "code": "0803", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Cycling Peritoneal Dialysis (CCPD)", "code_information": [ { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Other", "code_information": [ { "code": "0809", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Hemodialysis - Outpatient or Home - General Classification", "code_information": [ { "code": "0820", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis - Outpatient or Home - Hemodialysis Composite or Other Rate", "code_information": [ { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis - Outpatient or Home - Other OP Hemodialysis", "code_information": [ { "code": "0829", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Peritoneal Dialysis - Outpatient or Home - Peritoneal/Composite or Other Rate", "code_information": [ { "code": "0831", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis repeated eval", "code_information": [ { "code": "90937", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dialysis training incompl", "code_information": [ { "code": "90993", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted dialysis procedure", "code_information": [ { "code": "90999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Room & Board - Private (One Bed) - General Classification", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1050, "maximum": 1275 } ] }, { "description": "Room & Board - Private (One Bed) - Rehabilitation", "code_information": [ { "code": "0118", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "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": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "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": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "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": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "median_amount": 977.5, "10th_percentile": 977.5, "90th_percentile": 977.5, "count": "224" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 977.5, "maximum": 2450 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Rehabilitation", "code_information": [ { "code": "0128", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "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": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "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": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1050, "maximum": 2450 } ] }, { "description": "Physical Therapy - Other", "code_information": [ { "code": "0429", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "standard_charge_dollar": 250, "methodology": "fee schedule", "median_amount": 250, "10th_percentile": 250, "90th_percentile": 250, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 250, "methodology": "fee schedule", "median_amount": 250, "10th_percentile": 250, "90th_percentile": 250, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "standard_charge_dollar": 250, "methodology": "fee schedule", "median_amount": 250, "10th_percentile": 250, "90th_percentile": 250, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "standard_charge_dollar": 250, "methodology": "fee schedule", "median_amount": 250, "10th_percentile": 250, "90th_percentile": 250, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 250 } ] }, { "description": "Room & Board - Three and Four Beds - Rehabilitation", "code_information": [ { "code": "0138", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "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": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "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": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 2450 } ] }, { "description": "Room & Board - Deluxe Private - Rehabilitation", "code_information": [ { "code": "0148", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "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": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "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": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 2450 } ] }, { "description": "Room & Board - Ward - Rehabilitation", "code_information": [ { "code": "0158", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "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": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "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": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "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": "Cofinity", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "standard_charge_percentage": 70, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 2450 } ] }, { "description": "Pharmacy - General Classification", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Generic Drugs", "code_information": [ { "code": "0251", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Non-generic Drugs", "code_information": [ { "code": "0252", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Take Home Drugs", "code_information": [ { "code": "0253", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Incident To Other Diagnostic Services", "code_information": [ { "code": "0254", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Incident To Radiology", "code_information": [ { "code": "0255", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Experimental Drugs", "code_information": [ { "code": "0256", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Nonprescription", "code_information": [ { "code": "0257", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - IV Solutions", "code_information": [ { "code": "0258", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Other", "code_information": [ { "code": "0259", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - General Classification", "code_information": [ { "code": "0260", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Infusion Pump", "code_information": [ { "code": "0261", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Pharmacy Services", "code_information": [ { "code": "0262", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Drug/Supply Delivery", "code_information": [ { "code": "0263", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Supplies", "code_information": [ { "code": "0264", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Treatment", "code_information": [ { "code": "0265", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Continuation", "code_information": [ { "code": "0266", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Observation/Hourly", "code_information": [ { "code": "0267", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Other", "code_information": [ { "code": "0268", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Other", "code_information": [ { "code": "0269", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - General Classification", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Immunology", "code_information": [ { "code": "0302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Renal Patient (Home)", "code_information": [ { "code": "0303", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Non-routine Dialysis", "code_information": [ { "code": "0304", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Hematology", "code_information": [ { "code": "0305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Bacteriology & Microbiology", "code_information": [ { "code": "0306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Urology", "code_information": [ { "code": "0307", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Other", "code_information": [ { "code": "0308", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Other", "code_information": [ { "code": "0309", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - General Classification", "code_information": [ { "code": "0310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Cytology", "code_information": [ { "code": "0311", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Histology", "code_information": [ { "code": "0312", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Assessment", "code_information": [ { "code": "0313", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Biopsy", "code_information": [ { "code": "0314", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Treatment", "code_information": [ { "code": "0315", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Continuation", "code_information": [ { "code": "0316", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Observation/Hourly", "code_information": [ { "code": "0317", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Other", "code_information": [ { "code": "0318", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Other", "code_information": [ { "code": "0319", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - General Classification", "code_information": [ { "code": "0320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Angiocardiography", "code_information": [ { "code": "0321", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Arthrography", "code_information": [ { "code": "0322", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Arteriography", "code_information": [ { "code": "0323", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Chest X-Ray", "code_information": [ { "code": "0324", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Treatment", "code_information": [ { "code": "0325", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Continuation", "code_information": [ { "code": "0326", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Observation/Hourly", "code_information": [ { "code": "0327", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Other", "code_information": [ { "code": "0328", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Other", "code_information": [ { "code": "0329", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic and/or Chemotherapy Administration - General Classification", "code_information": [ { "code": "0330", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - Injected", "code_information": [ { "code": "0331", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - Oral", "code_information": [ { "code": "0332", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Radiation Therapy", "code_information": [ { "code": "0333", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Evaluation or Testing", "code_information": [ { "code": "0334", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - IV", "code_information": [ { "code": "0335", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Continuation", "code_information": [ { "code": "0336", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Observation/Hourly", "code_information": [ { "code": "0337", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Other", "code_information": [ { "code": "0338", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Other", "code_information": [ { "code": "0339", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - General Classification", "code_information": [ { "code": "0340", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Diagnostic Procedures", "code_information": [ { "code": "0341", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Therapeutic Procedures", "code_information": [ { "code": "0342", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Diagnostic Radiopharmaceuticals", "code_information": [ { "code": "0343", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Therapeutic Radiopharmaceuticals", "code_information": [ { "code": "0344", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Treatment", "code_information": [ { "code": "0345", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Continuation", "code_information": [ { "code": "0346", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Observation/Hourly", "code_information": [ { "code": "0347", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Other", "code_information": [ { "code": "0348", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Other", "code_information": [ { "code": "0349", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - General Classification", "code_information": [ { "code": "0350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Head Scan", "code_information": [ { "code": "0351", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Body Scan", "code_information": [ { "code": "0352", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Assessment", "code_information": [ { "code": "0353", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Evaluation or Testing", "code_information": [ { "code": "0354", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Treatment", "code_information": [ { "code": "0355", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Continuation", "code_information": [ { "code": "0356", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Observation/Hourly", "code_information": [ { "code": "0357", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Other", "code_information": [ { "code": "0358", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Other", "code_information": [ { "code": "0359", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - General Classification", "code_information": [ { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Minor Surgery", "code_information": [ { "code": "0361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Organ transplant - Other Than Kidney", "code_information": [ { "code": "0362", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Assessment", "code_information": [ { "code": "0363", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Evaluation or Testing", "code_information": [ { "code": "0364", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Treatment", "code_information": [ { "code": "0365", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Continuation", "code_information": [ { "code": "0366", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Kidney Transplant", "code_information": [ { "code": "0367", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Other", "code_information": [ { "code": "0368", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Other", "code_information": [ { "code": "0369", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - General Classification", "code_information": [ { "code": "0370", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Incident to Radiology", "code_information": [ { "code": "0371", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Incident to Other Diagnostic Services", "code_information": [ { "code": "0372", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Assessment", "code_information": [ { "code": "0373", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Acupuncture", "code_information": [ { "code": "0374", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Treatment", "code_information": [ { "code": "0375", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Continuation", "code_information": [ { "code": "0376", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Observation/Hourly", "code_information": [ { "code": "0377", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Other", "code_information": [ { "code": "0378", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Other", "code_information": [ { "code": "0379", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - General Classification", "code_information": [ { "code": "0400", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Diagnostic Mammography", "code_information": [ { "code": "0401", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Ultrasound", "code_information": [ { "code": "0402", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Screening Mammography", "code_information": [ { "code": "0403", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Positron Emission Tomography", "code_information": [ { "code": "0404", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Treatment", "code_information": [ { "code": "0405", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Continuation", "code_information": [ { "code": "0406", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Observation/Hourly", "code_information": [ { "code": "0407", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Other", "code_information": [ { "code": "0408", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Other", "code_information": [ { "code": "0409", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Visit", "code_information": [ { "code": "0411", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Inhalation Services", "code_information": [ { "code": "0412", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Hyperbaric Oxygen Therapy", "code_information": [ { "code": "0413", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Evaluation or Testing", "code_information": [ { "code": "0414", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Treatment", "code_information": [ { "code": "0415", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Continuation", "code_information": [ { "code": "0416", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Observation/Hourly", "code_information": [ { "code": "0417", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Other", "code_information": [ { "code": "0418", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Respiratory Services - Other", "code_information": [ { "code": "0419", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Physical Therapy - Hourly Charge", "code_information": [ { "code": "0422", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 120, "maximum": 150 } ] }, { "description": "Physical Therapy - Group Rate", "code_information": [ { "code": "0423", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 120, "maximum": 150 } ] }, { "description": "Physical Therapy - Treatment", "code_information": [ { "code": "0425", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Physical Therapy - Continuation", "code_information": [ { "code": "0426", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Physical Therapy - Observation/Hourly", "code_information": [ { "code": "0427", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Physical Therapy - Other", "code_information": [ { "code": "0428", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Occupational Therapy - Visit Charge", "code_information": [ { "code": "0431", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Occupational Therapy - Hourly Charge", "code_information": [ { "code": "0432", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Occupational Therapy - Group Rate", "code_information": [ { "code": "0433", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Occupational Therapy - Treatment", "code_information": [ { "code": "0435", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Occupational Therapy - Continuation", "code_information": [ { "code": "0436", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Occupational Therapy - Observation/Hourly", "code_information": [ { "code": "0437", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Occupational Therapy - Other", "code_information": [ { "code": "0438", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Occupational Therapy - Other", "code_information": [ { "code": "0439", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Speech Therapy - Language Pathology - Visit Charge", "code_information": [ { "code": "0441", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Speech Therapy - Language Pathology - Hourly Charge", "code_information": [ { "code": "0442", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Speech Therapy - Language Pathology - Group Rate", "code_information": [ { "code": "0443", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 150, "methodology": "per diem", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 140, "maximum": 150 } ] }, { "description": "Speech-Language Pathology - Treatment", "code_information": [ { "code": "0445", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech-Language Pathology - Continuation", "code_information": [ { "code": "0446", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech-Language Pathology - Observation/Hourly", "code_information": [ { "code": "0447", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech-Language Pathology - Other", "code_information": [ { "code": "0448", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech Therapy - Language Pathology - Other", "code_information": [ { "code": "0449", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 140, "methodology": "fee schedule", "median_amount": 140, "10th_percentile": 140, "90th_percentile": 140, "count": "1 through 10" } ], "minimum": 140, "maximum": 140 } ] }, { "description": "Emergency Room - General Classification", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - EMTALA Emergency Medical Screening Services", "code_information": [ { "code": "0451", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Beyond EMTALA Screening", "code_information": [ { "code": "0452", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Assessment", "code_information": [ { "code": "0453", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Evaluation or Testing", "code_information": [ { "code": "0454", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Treatment", "code_information": [ { "code": "0455", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Urgent Care", "code_information": [ { "code": "0456", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Observation/Hourly", "code_information": [ { "code": "0457", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Other", "code_information": [ { "code": "0458", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Other", "code_information": [ { "code": "0459", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - General Classification", "code_information": [ { "code": "0460", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Visit", "code_information": [ { "code": "0461", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Unit", "code_information": [ { "code": "0462", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Assessment", "code_information": [ { "code": "0463", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Evaluation or Testing", "code_information": [ { "code": "0464", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Treatment", "code_information": [ { "code": "0465", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Continuation", "code_information": [ { "code": "0466", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Observation/Hourly", "code_information": [ { "code": "0467", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Other", "code_information": [ { "code": "0468", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Other", "code_information": [ { "code": "0469", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - General Classification", "code_information": [ { "code": "0470", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Diagnostic", "code_information": [ { "code": "0471", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Treatment", "code_information": [ { "code": "0472", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Assessment", "code_information": [ { "code": "0473", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Evaluation or Testing", "code_information": [ { "code": "0474", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Treatment", "code_information": [ { "code": "0475", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Continuation", "code_information": [ { "code": "0476", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Observation/Hourly", "code_information": [ { "code": "0477", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Other", "code_information": [ { "code": "0478", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Other", "code_information": [ { "code": "0479", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - General Classification", "code_information": [ { "code": "0480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Cardiac Cath Lab", "code_information": [ { "code": "0481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Stress Test", "code_information": [ { "code": "0482", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Echocardiology", "code_information": [ { "code": "0483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Evaluation or Testing", "code_information": [ { "code": "0484", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Treatment", "code_information": [ { "code": "0485", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Continuation", "code_information": [ { "code": "0486", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Observation/Hourly", "code_information": [ { "code": "0487", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Other", "code_information": [ { "code": "0488", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Other", "code_information": [ { "code": "0489", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - General Classification", "code_information": [ { "code": "0490", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - General Classification", "code_information": [ { "code": "0510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Chronic Pain Center", "code_information": [ { "code": "0511", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Dental", "code_information": [ { "code": "0512", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Psychiatric", "code_information": [ { "code": "0513", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - OB-GYN", "code_information": [ { "code": "0514", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Pediatric", "code_information": [ { "code": "0515", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Urgent Care", "code_information": [ { "code": "0516", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Family Practice", "code_information": [ { "code": "0517", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Other", "code_information": [ { "code": "0518", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Other", "code_information": [ { "code": "0519", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - General Classification", "code_information": [ { "code": "0520", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Clinic visit by member to RHC/FQHC", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Home visit by RHC/FQHC practitioner", "code_information": [ { "code": "0522", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Family Practice", "code_information": [ { "code": "0523", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to a member in a SNF or Skilled Swing Bed in a covered Part A stay", "code_information": [ { "code": "0524", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility", "code_information": [ { "code": "0525", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Urgent Care", "code_information": [ { "code": "0526", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - RHC/FQHC Visiting Nurse Service(s) to a member's home when in a home health shortage area", "code_information": [ { "code": "0527", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)", "code_information": [ { "code": "0528", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Other", "code_information": [ { "code": "0529", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - General Classification", "code_information": [ { "code": "0610", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - General Classification", "code_information": [ { "code": "0730", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Holter Monitor", "code_information": [ { "code": "0731", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Telemetry", "code_information": [ { "code": "0732", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Assessment", "code_information": [ { "code": "0733", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Evaluation or Testing", "code_information": [ { "code": "0734", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Treatment", "code_information": [ { "code": "0735", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Continuation", "code_information": [ { "code": "0736", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Observation/Hourly", "code_information": [ { "code": "0737", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Other", "code_information": [ { "code": "0738", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Other", "code_information": [ { "code": "0739", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG (Electroencephalogram) - General Classification", "code_information": [ { "code": "0740", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Visit", "code_information": [ { "code": "0741", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Unit", "code_information": [ { "code": "0742", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Assessment", "code_information": [ { "code": "0743", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Evaluation or Testing", "code_information": [ { "code": "0744", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Treatment", "code_information": [ { "code": "0745", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Continuation", "code_information": [ { "code": "0746", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Observation/Hourly", "code_information": [ { "code": "0747", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Other", "code_information": [ { "code": "0748", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Other", "code_information": [ { "code": "0749", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Psychiatric/psychological services-general classification", "code_information": [ { "code": "0910", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Rehabilitation", "code_information": [ { "code": "0911", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Partial Hospitalization - Less Intensive", "code_information": [ { "code": "0912", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Partial Hospitalization - Intensive", "code_information": [ { "code": "0913", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Individual Therapy", "code_information": [ { "code": "0914", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Group Therapy", "code_information": [ { "code": "0915", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Family Therapy", "code_information": [ { "code": "0916", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Bio Feedback", "code_information": [ { "code": "0917", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Testing", "code_information": [ { "code": "0918", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Other", "code_information": [ { "code": "0919", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - General Classification", "code_information": [ { "code": "0920", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Peripheral Vascular Lab", "code_information": [ { "code": "0921", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Electromyogram", "code_information": [ { "code": "0922", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Pap Smear", "code_information": [ { "code": "0923", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Allergy Test", "code_information": [ { "code": "0924", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Pregnancy Test", "code_information": [ { "code": "0925", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Continuation", "code_information": [ { "code": "0926", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Observation/Hourly", "code_information": [ { "code": "0927", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Other", "code_information": [ { "code": "0928", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Other Diagnostic Service", "code_information": [ { "code": "0929", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - General Classification", "code_information": [ { "code": "0930", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Rehabilitation Day Program - Half Day", "code_information": [ { "code": "0931", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Assessment", "code_information": [ { "code": "0933", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Evaluation or Testing", "code_information": [ { "code": "0934", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Treatment", "code_information": [ { "code": "0935", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Continuation", "code_information": [ { "code": "0936", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Observation/Hourly", "code_information": [ { "code": "0937", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Other", "code_information": [ { "code": "0938", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Other", "code_information": [ { "code": "0939", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - General Classification", "code_information": [ { "code": "0940", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Recreational Therapy", "code_information": [ { "code": "0941", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Education/Training", "code_information": [ { "code": "0942", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Cardiac Rehabilitation", "code_information": [ { "code": "0943", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Drug Rehabilitation", "code_information": [ { "code": "0944", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Alcohol Rehabilitation", "code_information": [ { "code": "0945", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Complex Medical Equipment - Routine", "code_information": [ { "code": "0946", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Complex Medical Equipment - Ancillary", "code_information": [ { "code": "0947", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Pulmonary Rehabilitation", "code_information": [ { "code": "0948", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Other", "code_information": [ { "code": "0949", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth ear surgery", "code_information": [ { "code": "00120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth head/neck/ptrunk", "code_information": [ { "code": "00300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck organ 1yr/>", "code_information": [ { "code": "00320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of breast", "code_information": [ { "code": "00402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth correct heart rhythm", "code_information": [ { "code": "00410", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of shoulder", "code_information": [ { "code": "00450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth abdominal wall surg", "code_information": [ { "code": "00730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth vasectomy", "code_information": [ { "code": "00921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fna bx w/us gdn 1st les", "code_information": [ { "code": "10005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I&d abscess simple/single", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I&d abscess comp/multiple", "code_information": [ { "code": "10061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dbrdmt subq tiss each addl", "code_information": [ { "code": "11045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 1.1-2", "code_information": [ { "code": "11422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk 2.5cm/<", "code_information": [ { "code": "12001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk2.6-7.5cm", "code_information": [ { "code": "12002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trk7.6-12.5cm", "code_information": [ { "code": "12004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.5 cm/<", "code_information": [ { "code": "12011", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.6-5.0 cm", "code_information": [ { "code": "12013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.6-7.5", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tis trnfr trunk 10 sq cm/<", "code_information": [ { "code": "14000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tis trnfr s/a/l 10 sq cm/<", "code_information": [ { "code": "14020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Grfg autol fat lipo 50 cc/<", "code_information": [ { "code": "15771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Grfg autol fat lipo ea addl", "code_information": [ { "code": "15772", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal sutr/stapl xreq anes", "code_information": [ { "code": "15853", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dress/debrid p-thick burn s", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bx breast 1st lesion strtctc", "code_information": [ { "code": "19081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bx breast 1st lesion us imag", "code_information": [ { "code": "19083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of breast lesion", "code_information": [ { "code": "19120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq device breast 1st imag", "code_information": [ { "code": "19281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq dev breast 1st us imag", "code_information": [ { "code": "19285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Partial mastectomy", "code_information": [ { "code": "19301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "P-mastectomy w/ln removal", "code_information": [ { "code": "19302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mast simple complete", "code_information": [ { "code": "19303", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mast mod rad", "code_information": [ { "code": "19307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone biopsy trocar/ndl deep", "code_information": [ { "code": "20225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of implant deep", "code_information": [ { "code": "20680", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cptr-asst dir ms px", "code_information": [ { "code": "20985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc face tum deep 2 cm/>", "code_information": [ { "code": "21014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc neck les sc 3 cm/>", "code_information": [ { "code": "21552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc back les sc 3 cm/>", "code_information": [ { "code": "21931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteot dsc ant 1vrt sgm lmbr", "code_information": [ { "code": "22224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22513", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arthrd ant toral/xoral c1-c2", "code_information": [ { "code": "22548", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arthrd ant ntrbd cervical ea", "code_information": [ { "code": "22552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair rotator cuff chronic", "code_information": [ { "code": "23412", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Optx clavicular fx w/int fix", "code_information": [ { "code": "23515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cltx sho dslc w/mnpj wo anes", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruct elbow lat ligmnt", "code_information": [ { "code": "24344", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of humerus", "code_information": [ { "code": "24430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat humerus fracture", "code_information": [ { "code": "24516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat elbow dislocation", "code_information": [ { "code": "24615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat ulnar fracture", "code_information": [ { "code": "24685", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fx rad extra-articul", "code_information": [ { "code": "25607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fx rad intra-articul", "code_information": [ { "code": "25608", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fracture ulnar styloid", "code_information": [ { "code": "25652", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat thumb fracture", "code_information": [ { "code": "26645", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revision of unstable kneecap", "code_information": [ { "code": "27422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lat retinacular release open", "code_information": [ { "code": "27425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruction knee", "code_information": [ { "code": "27427", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revision of knee joint", "code_information": [ { "code": "27446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total knee arthroplasty", "code_information": [ { "code": "27447", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat kneecap fracture", "code_information": [ { "code": "27524", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fixation of knee joint", "code_information": [ { "code": "27570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruction ankle joint", "code_information": [ { "code": "27703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Realignment of lower leg", "code_information": [ { "code": "27712", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of hammertoe", "code_information": [ { "code": "28285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat/graft heel fracture", "code_information": [ { "code": "28420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply long arm splint", "code_information": [ { "code": "29105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application long leg splint", "code_information": [ { "code": "29505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application lower leg splint", "code_information": [ { "code": "29515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs dx +- synovial bx", "code_information": [ { "code": "29805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg lmtd dbrdmt", "code_information": [ { "code": "29822", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg decompression", "code_information": [ { "code": "29826", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg rt8tr cuf rpr", "code_information": [ { "code": "29827", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg bicp tenodsis", "code_information": [ { "code": "29828", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29881", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Excise inferior turbinate", "code_information": [ { "code": "30130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resect inferior turbinate", "code_information": [ { "code": "30140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of nasal septum", "code_information": [ { "code": "30520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ablate inf turbinate superf", "code_information": [ { "code": "30801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc surg bx polypc", "code_information": [ { "code": "31237", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc w/prtl ethmdct", "code_information": [ { "code": "31254", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exploration maxillary sinus", "code_information": [ { "code": "31256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc tot w/sphendt", "code_information": [ { "code": "31257", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc sphn tiss rmvl", "code_information": [ { "code": "31259", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscopy maxillary sinus", "code_information": [ { "code": "31267", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc frnt tiss rmvl", "code_information": [ { "code": "31276", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nasal/sinus endoscopy surg", "code_information": [ { "code": "31288", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert emergency airway", "code_information": [ { "code": "31500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Core ndl bx lng/med perq", "code_information": [ { "code": "32408", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aspirate pleura w/ imaging", "code_information": [ { "code": "32555", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert heart pm ventricular", "code_information": [ { "code": "33207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove&replace pm gen singl", "code_information": [ { "code": "33227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remv&replc pm gen dual lead", "code_information": [ { "code": "33228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place catheter in vein", "code_information": [ { "code": "36012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place catheter in aorta", "code_information": [ { "code": "36200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place cath subclavian art", "code_information": [ { "code": "36225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ins cath abd/l-ext art 3rd", "code_information": [ { "code": "36247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ins cath abd/l-ext art addl", "code_information": [ { "code": "36248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Routine venipuncture", "code_information": [ { "code": "36415", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transfusion bld/bld compnt", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrauterine transfusion ftl", "code_information": [ { "code": "36460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apheresis plasma", "code_information": [ { "code": "36514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj picc 5 yr+ w/o imaging", "code_information": [ { "code": "36569", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj picc rs&i 5 yr+", "code_information": [ { "code": "36573", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36589", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reposition venous catheter", "code_information": [ { "code": "36597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Withdrawal of arterial blood", "code_information": [ { "code": "36600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fuse uppr arm basilic", "code_information": [ { "code": "36819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fusion direct any site", "code_information": [ { "code": "36821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery-vein nonautograft", "code_information": [ { "code": "36830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fistula revision open", "code_information": [ { "code": "36832", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36903", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36906", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Balo angiop ctr dialysis seg", "code_information": [ { "code": "36907", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dialysis circuit embolj", "code_information": [ { "code": "36909", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rem endovas vena cava filter", "code_information": [ { "code": "37193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrombolytic art therapy", "code_information": [ { "code": "37211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fem/popl revas w/tla", "code_information": [ { "code": "37224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fem/popl revas w/ather", "code_information": [ { "code": "37225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc w/tla", "code_information": [ { "code": "37228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc w/ather", "code_information": [ { "code": "37229", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc add-on", "code_information": [ { "code": "37232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tibper revasc w/ather add-on", "code_information": [ { "code": "37233", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open/perq place stent same", "code_information": [ { "code": "37238", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open/perq place stent ea add", "code_information": [ { "code": "37239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vasc embolize/occlude organ", "code_information": [ { "code": "37243", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trluml balo angiop 1st art", "code_information": [ { "code": "37246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrvasc us noncoronary 1st", "code_information": [ { "code": "37252", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrvasc us noncoronary addl", "code_information": [ { "code": "37253", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Phleb veins - extrem 20+", "code_information": [ { "code": "37766", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx bone marrow bx & aspir", "code_information": [ { "code": "38222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle biopsy lymph nodes", "code_information": [ { "code": "38505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open bx/exc inguinofem nodes", "code_information": [ { "code": "38531", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy lymph node biop", "code_information": [ { "code": "38570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy lymphadenectomy", "code_information": [ { "code": "38571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Io map of sent lymph node", "code_information": [ { "code": "38900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove tonsils and adenoids", "code_information": [ { "code": "42821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of tonsils", "code_information": [ { "code": "42826", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd diagnostic brush wash", "code_information": [ { "code": "43235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd biopsy single/multiple", "code_information": [ { "code": "43239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd varices ligation", "code_information": [ { "code": "43244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd place gastrostomy tube", "code_information": [ { "code": "43246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy fundoplasty", "code_information": [ { "code": "43280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reposition gastrostomy tube", "code_information": [ { "code": "43761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rplc gtube no revj trc", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy appendectomy", "code_information": [ { "code": "44970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Proctosigmoidoscopy dx", "code_information": [ { "code": "45300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Diagnostic colonoscopy", "code_information": [ { "code": "45378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy and biopsy", "code_information": [ { "code": "45380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy submucous njx", "code_information": [ { "code": "45381", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy w/ablation", "code_information": [ { "code": "45388", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove int/ext hem 1 group", "code_information": [ { "code": "46255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove in/ex hem groups 2+", "code_information": [ { "code": "46260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Diagnostic anoscopy & biopsy", "code_information": [ { "code": "46607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Destruction anal lesion(s)", "code_information": [ { "code": "46924", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle biopsy of liver", "code_information": [ { "code": "47000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopic cholecystectomy", "code_information": [ { "code": "47562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo cholecystectomy/graph", "code_information": [ { "code": "47563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abd paracentesis w/imaging", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy aspiration", "code_information": [ { "code": "49322", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap insert tunnel ip cath", "code_information": [ { "code": "49324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove tunneled ip cath", "code_information": [ { "code": "49422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prp i/hern init reduc >5 yr", "code_information": [ { "code": "49505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prp i/hern init block >5 yr", "code_information": [ { "code": "49507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rerepair ing hernia reduce", "code_information": [ { "code": "49520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st < 3 cm rdc", "code_information": [ { "code": "49591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st < 3 ncr/strn", "code_information": [ { "code": "49592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st 3-10 ncr/strn", "code_information": [ { "code": "49594", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap ing hernia repair init", "code_information": [ { "code": "49650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap ing hernia repair recur", "code_information": [ { "code": "49651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exchange nephrostomy cath", "code_information": [ { "code": "50435", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo partial nephrectomy", "code_information": [ { "code": "50543", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fragmenting of kidney stone", "code_information": [ { "code": "50590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted laps px ureter", "code_information": [ { "code": "50949", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drain bl w/cath insertion", "code_information": [ { "code": "51102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert temp bladder cath", "code_information": [ { "code": "51702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us urine capacity measure", "code_information": [ { "code": "51798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy w/biopsy(s)", "code_information": [ { "code": "52204", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52234", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52240", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52317", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cysto/uretero w/lithotripsy", "code_information": [ { "code": "52356", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prostatectomy (turp)", "code_information": [ { "code": "52601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert uro/ves nck sphincter", "code_information": [ { "code": "53445", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Circum 28 days or older", "code_information": [ { "code": "54161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of hydrocele", "code_information": [ { "code": "55040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy of prostate", "code_information": [ { "code": "55700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abltj mal prst8 tiss hifu", "code_information": [ { "code": "55880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cmbn ant pst colprhy", "code_information": [ { "code": "57260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair bladder defect", "code_information": [ { "code": "57288", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Conz of cervix w/scope leep", "code_information": [ { "code": "57461", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Conization of cervix", "code_information": [ { "code": "57522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dilation and curettage", "code_information": [ { "code": "58120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove intrauterine device", "code_information": [ { "code": "58301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-asst vag hysterectomy", "code_information": [ { "code": "58550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-vag hyst incl t/o", "code_information": [ { "code": "58552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-vag hyst w/t/o compl", "code_information": [ { "code": "58554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy biopsy", "code_information": [ { "code": "58558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy remove myoma", "code_information": [ { "code": "58561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy ablation", "code_information": [ { "code": "58563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tlh uterus 250 g or less", "code_information": [ { "code": "58570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tlh w/t/o 250 g or less", "code_information": [ { "code": "58571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy remove adnexa", "code_information": [ { "code": "58661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy excise lesions", "code_information": [ { "code": "58662", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal cord puncture prenatal", "code_information": [ { "code": "59012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal non-stress test", "code_information": [ { "code": "59025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Care of miscarriage", "code_information": [ { "code": "59820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted fetal invas px w/us", "code_information": [ { "code": "59897", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Partial removal of thyroid", "code_information": [ { "code": "60220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Scan proc cranial extra", "code_information": [ { "code": "61782", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx lmbr spi pnxr", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx lmbr spi pnxr w/fluor/ct", "code_information": [ { "code": "62328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Njx aa&/strd other pn/branch", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revise ulnar nerve at elbow", "code_information": [ { "code": "64718", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carpal tunnel surgery", "code_information": [ { "code": "64721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of eye lesion", "code_information": [ { "code": "65426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65755", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal trnspl endothelial", "code_information": [ { "code": "65756", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Relieve inner eye pressure", "code_information": [ { "code": "65820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Glaucoma surgery", "code_information": [ { "code": "66170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aqueous shunt eye w/graft", "code_information": [ { "code": "66180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Follow-up surgery of eye", "code_information": [ { "code": "66250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Incision of iris", "code_information": [ { "code": "66500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66625", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "After cataract laser surgery", "code_information": [ { "code": "66821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl cplx wo ecp", "code_information": [ { "code": "66982", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl w/o ecp", "code_information": [ { "code": "66984", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl insj 1+", "code_information": [ { "code": "66991", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection eye drug", "code_information": [ { "code": "67028", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dstrj extensive retinopathy", "code_information": [ { "code": "67227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reinforce/graft eye wall", "code_information": [ { "code": "67255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove eyelid lesion", "code_information": [ { "code": "67800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove impacted ear wax uni", "code_information": [ { "code": "69209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of nasal bones", "code_information": [ { "code": "70160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of neck", "code_information": [ { "code": "70360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct head/brain w/o dye", "code_information": [ { "code": "70450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct orbit/ear/fossa w/o dye", "code_information": [ { "code": "70480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct maxillofacial w/o dye", "code_information": [ { "code": "70486", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct maxillofacial w/dye", "code_information": [ { "code": "70487", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct soft tissue neck w/o dye", "code_information": [ { "code": "70490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct soft tissue neck w/dye", "code_information": [ { "code": "70491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography head", "code_information": [ { "code": "70496", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography neck", "code_information": [ { "code": "70498", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri brain stem w/o dye", "code_information": [ { "code": "70551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri brain stem w/o & w/dye", "code_information": [ { "code": "70553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs uni 2 views", "code_information": [ { "code": "71100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam unilat ribs/chest", "code_information": [ { "code": "71101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs bil 3 views", "code_information": [ { "code": "71110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs/chest4/> vws", "code_information": [ { "code": "71111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct thorax dx c-", "code_information": [ { "code": "71250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct thorax dx c+", "code_information": [ { "code": "71260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography chest", "code_information": [ { "code": "71275", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of spine 1 view", "code_information": [ { "code": "72020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam neck spine 2-3 vw", "code_information": [ { "code": "72040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam neck spine 4/5vws", "code_information": [ { "code": "72050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam thorac spine 2vws", "code_information": [ { "code": "72070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam thorac spine 3vws", "code_information": [ { "code": "72072", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam l-s spine 2/3 vws", "code_information": [ { "code": "72100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam l-2 spine 4/>vws", "code_information": [ { "code": "72110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct neck spine w/o dye", "code_information": [ { "code": "72125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct chest spine w/o dye", "code_information": [ { "code": "72128", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lumbar spine w/o dye", "code_information": [ { "code": "72131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri neck spine w/o dye", "code_information": [ { "code": "72141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri chest spine w/o dye", "code_information": [ { "code": "72146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri lumbar spine w/o dye", "code_information": [ { "code": "72148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri neck spine w/o & w/dye", "code_information": [ { "code": "72156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiograph pelv w/o&w/dye", "code_information": [ { "code": "72191", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct pelvis w/o dye", "code_information": [ { "code": "72192", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct pelvis w/dye", "code_information": [ { "code": "72193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri pelvis w/o dye", "code_information": [ { "code": "72195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri pelvis w/o & w/dye", "code_information": [ { "code": "72197", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam sacrum tailbone", "code_information": [ { "code": "72220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of collar bone", "code_information": [ { "code": "73000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of humerus", "code_information": [ { "code": "73060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of forearm", "code_information": [ { "code": "73090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of finger(s)", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct upper extremity w/o dye", "code_information": [ { "code": "73200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri joint upr extrem w/o dye", "code_information": [ { "code": "73221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 1 view", "code_information": [ { "code": "73501", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 2-3 views", "code_information": [ { "code": "73502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 4/> views", "code_information": [ { "code": "73503", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hips bi 2 views", "code_information": [ { "code": "73521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hips bi 3-4 views", "code_information": [ { "code": "73522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of femur 1", "code_information": [ { "code": "73551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of femur 2/>", "code_information": [ { "code": "73552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knee 3", "code_information": [ { "code": "73562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam knee 4 or more", "code_information": [ { "code": "73564", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knees", "code_information": [ { "code": "73565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of lower leg", "code_information": [ { "code": "73590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of toe(s)", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lower extremity w/o dye", "code_information": [ { "code": "73700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lower extremity w/dye", "code_information": [ { "code": "73701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri jnt of lwr extre w/o dye", "code_information": [ { "code": "73721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam complete abdomen", "code_information": [ { "code": "74022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abdomen w/o dye", "code_information": [ { "code": "74150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abdomen w/o & w/dye", "code_information": [ { "code": "74170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abd&pelv w/o&w/dye", "code_information": [ { "code": "74174", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abdom w/o & w/dye", "code_information": [ { "code": "74175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelvis w/o contrast", "code_information": [ { "code": "74176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelv 1/> regns", "code_information": [ { "code": "74178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri abdomen w/o dye", "code_information": [ { "code": "74181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri abdomen w/o & w/dye", "code_information": [ { "code": "74183", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray xm swlng funcj c+", "code_information": [ { "code": "74230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray xm sm int 1cntrst std", "code_information": [ { "code": "74250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray bile/panc endoscopy", "code_information": [ { "code": "74330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio hrt w/3d image", "code_information": [ { "code": "75574", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray aorta leg arteries", "code_information": [ { "code": "75630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abdominal arteries", "code_information": [ { "code": "75635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery x-rays arms/legs", "code_information": [ { "code": "75716", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery x-rays abdomen", "code_information": [ { "code": "75726", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray arm/leg", "code_information": [ { "code": "75820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray arms/legs", "code_information": [ { "code": "75822", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray trunk", "code_information": [ { "code": "75825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray chest", "code_information": [ { "code": "75827", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluoroscopy <1 hr phys/qhp", "code_information": [ { "code": "76000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam surgical specimen", "code_information": [ { "code": "76098", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cat scan follow-up study", "code_information": [ { "code": "76380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo exam of eye thickness", "code_information": [ { "code": "76514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam of head and neck", "code_information": [ { "code": "76536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ultrasound breast complete", "code_information": [ { "code": "76641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo exam of abdomen", "code_information": [ { "code": "76705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam abdo back wall comp", "code_information": [ { "code": "76770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us < 14 wks single fetus", "code_information": [ { "code": "76801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us >= 14 wks sngl fetus", "code_information": [ { "code": "76805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us detailed sngl fetus", "code_information": [ { "code": "76811", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatobiliary system imaging", "code_information": [ { "code": "78226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gastric emptying imag study", "code_information": [ { "code": "78264", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone imaging whole body", "code_information": [ { "code": "78306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Motion fluoroscopy/swallow", "code_information": [ { "code": "92611", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed same phys/qhp 5/>yrs", "code_information": [ { "code": "99152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Fentanyl citrate injection", "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "00406-1130-52", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "ROOM & BOARD - HOSPITAL AT HOME", "code_information": [ { "code": "0161", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Locm 300-399mg/ml iodine,1ml", "code_information": [ { "code": "Q9967", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "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": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INITIAL INFANT HEAR-SCREEN-HOSP/INP", "code_information": [ { "code": "Z9725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Room & Board - Other - Sterile Environment", "code_information": [ { "code": "0164", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Other - Other", "code_information": [ { "code": "0169", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Nursery - Other", "code_information": [ { "code": "0179", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Coronary Care Unit - Intermediate CCU", "code_information": [ { "code": "0214", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Coronary Care Unit - Other", "code_information": [ { "code": "0219", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "All Inclusive Rate - Room and Board Plus Ancillary", "code_information": [ { "code": "0100", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "All Inclusive Rate - Room and Board", "code_information": [ { "code": "0101", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Private (One Bed) - Medical/Surgical/GYN", "code_information": [ { "code": "0111", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Private (One Bed) - Obstetrics (OB)", "code_information": [ { "code": "0112", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Private (One Bed) - Pediatric", "code_information": [ { "code": "0113", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Private (One Bed) - Oncology", "code_information": [ { "code": "0117", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Private (One Bed) - Other", "code_information": [ { "code": "0119", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - General Classification", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Medical/Surgical/GYN", "code_information": [ { "code": "0121", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Obstetrics (OB)", "code_information": [ { "code": "0122", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Pediatric", "code_information": [ { "code": "0123", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Oncology", "code_information": [ { "code": "0127", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Other", "code_information": [ { "code": "0129", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - General Classification", "code_information": [ { "code": "0130", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Medical/Surgical/GYN", "code_information": [ { "code": "0131", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Obstetrics (OB)", "code_information": [ { "code": "0132", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Pediatric", "code_information": [ { "code": "0133", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Oncology", "code_information": [ { "code": "0137", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Other", "code_information": [ { "code": "0139", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - General Classification", "code_information": [ { "code": "0140", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Medical/Surgical/GYN", "code_information": [ { "code": "0141", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Obstetrics (OB)", "code_information": [ { "code": "0142", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Pediatric", "code_information": [ { "code": "0143", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Oncology", "code_information": [ { "code": "0147", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Other", "code_information": [ { "code": "0149", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - General Classification", "code_information": [ { "code": "0150", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Medical/Surgical/GYN", "code_information": [ { "code": "0151", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Obstetrics (OB)", "code_information": [ { "code": "0152", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Pediatrics", "code_information": [ { "code": "0153", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Oncology", "code_information": [ { "code": "0157", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Other", "code_information": [ { "code": "0159", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Room & Board - Other - General Classification", "code_information": [ { "code": "0160", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Nursery - General Classification", "code_information": [ { "code": "0170", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Nursery - Newborn - Level I", "code_information": [ { "code": "0171", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Nursery - Newborn - Level II", "code_information": [ { "code": "0172", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Nursery - Newborn - Level III", "code_information": [ { "code": "0173", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Nursery - Newborn - Level IV", "code_information": [ { "code": "0174", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - General Classification", "code_information": [ { "code": "0200", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Surgical", "code_information": [ { "code": "0201", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Medical", "code_information": [ { "code": "0202", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Pediatric", "code_information": [ { "code": "0203", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Intermediate ICU", "code_information": [ { "code": "0206", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Burn Care", "code_information": [ { "code": "0207", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Trauma", "code_information": [ { "code": "0208", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Intensive Care Unit - Other", "code_information": [ { "code": "0209", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Coronary Care Unit - General Classification", "code_information": [ { "code": "0210", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Coronary Care Unit - Myocardial Infarction", "code_information": [ { "code": "0211", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Coronary Care Unit - Pulmonary Care", "code_information": [ { "code": "0212", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "standard_charge_dollar": 1275, "methodology": "per diem", "median_amount": 1275, "10th_percentile": 1275, "90th_percentile": 1275, "count": "1 through 10" } ], "minimum": 1275, "maximum": 1275 } ] }, { "description": "Evaluation of speech fluency", "code_information": [ { "code": "92521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Oral speech device eval", "code_information": [ { "code": "92597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Ex for nonspeech device rx", "code_information": [ { "code": "92605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Non-speech device service", "code_information": [ { "code": "92606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Inj desmopressin acetate", "code_information": [ { "code": "J2597", "type": "HCPCS" }, { "code": "00409-2265-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Icatibant injection", "code_information": [ { "code": "J1744", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Phentolaine mesylate inj", "code_information": [ { "code": "J2760", "type": "HCPCS" }, { "code": "00143-9564-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 aripiprazole ext rel 1mg", "code_information": [ { "code": "J0401", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj filgrastim excl biosimil", "code_information": [ { "code": "J1442", "type": "HCPCS" }, { "code": "55513-0209-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.8, "type": "ML" } }, { "description": "Injection, pertuzumab, 1 mg", "code_information": [ { "code": "J9306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj beta interferon im 1 mcg", "code_information": [ { "code": "Q3027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Certolizumab pegol inj 1mg", "code_information": [ { "code": "J0717", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Golimumab for iv use 1mg", "code_information": [ { "code": "J1602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Obinutuzumab inj", "code_information": [ { "code": "J9301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj human fibrinogen con nos", "code_information": [ { "code": "J7178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Elosulfase alfa, injection", "code_information": [ { "code": "J1322", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Darbepoetin alfa, esrd use", "code_information": [ { "code": "J0882", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ferumoxytol, esrd use", "code_information": [ { "code": "Q0139", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor ix alprolix recomb", "code_information": [ { "code": "J7201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, ramucirumab", "code_information": [ { "code": "J9308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, vedolizumab", "code_information": [ { "code": "J3380", "type": "HCPCS" }, { "code": "64764-0300-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj pembrolizumab", "code_information": [ { "code": "J9271", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Etanercept injection", "code_information": [ { "code": "J1438", "type": "HCPCS" }, { "code": "54868-5444-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.98, "type": "ML" } }, { "description": "Rho(d) immune globulin h, sd", "code_information": [ { "code": "J2792", "type": "HCPCS" }, { "code": "49591-0300-51", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 13, "type": "ML" } }, { "description": "Inj trastuzumab excl biosimi", "code_information": [ { "code": "J9355", "type": "HCPCS" }, { "code": "50242-0132-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Hep b ig im", "code_information": [ { "code": "90371", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Y90 ibritumomab, rx", "code_information": [ { "code": "A9543", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor viii fc fusion recomb", "code_information": [ { "code": "J7205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, belinostat, 10mg", "code_information": [ { "code": "J9032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, oritavancin", "code_information": [ { "code": "J2407", "type": "HCPCS" }, { "code": "70842-0140-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 3, "type": "EA" } }, { "description": "Inj tedizolid phosphate", "code_information": [ { "code": "J3090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Florbetapir f18", "code_information": [ { "code": "A9586", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tetanus immune globulin inj", "code_information": [ { "code": "J1670", "type": "HCPCS" }, { "code": "13533-0634-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "P32 na phosphate", "code_information": [ { "code": "A9563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Basiliximab", "code_information": [ { "code": "J0480", "type": "HCPCS" }, { "code": "00078-0331-84", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Darbepoetin alfa, non-esrd", "code_information": [ { "code": "J0881", "type": "HCPCS" }, { "code": "55513-0002-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Epoetin alfa, non-esrd", "code_information": [ { "code": "J0885", "type": "HCPCS" }, { "code": "00069-1305-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Digoxin immune fab (ovine)", "code_information": [ { "code": "J1162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ethanolamine oleate 100 mg", "code_information": [ { "code": "J1430", "type": "HCPCS" }, { "code": "67871-4790-06", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Fomepizole, 15 mg", "code_information": [ { "code": "J1451", "type": "HCPCS" }, { "code": "00517-0710-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1.5, "type": "ML" } }, { "description": "Hemin, 1 mg", "code_information": [ { "code": "J1640", "type": "HCPCS" }, { "code": "55292-0702-54", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Ziconotide injection", "code_information": [ { "code": "J2278", "type": "HCPCS" }, { "code": "18860-0720-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Palifermin injection", "code_information": [ { "code": "J2425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj secretin synthetic human", "code_information": [ { "code": "J2850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treprostinil injection", "code_information": [ { "code": "J3285", "type": "HCPCS" }, { "code": "00703-0666-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Humate-p, inj", "code_information": [ { "code": "J7187", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor viia recomb novoseven", "code_information": [ { "code": "J7189", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clofarabine injection", "code_information": [ { "code": "J9027", "type": "HCPCS" }, { "code": "00024-5860-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Paclitaxel protein bound", "code_information": [ { "code": "J9264", "type": "HCPCS" }, { "code": "00480-3290-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Radium ra223 dichloride ther", "code_information": [ { "code": "A9606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Flortaucipir inj 1 millicuri", "code_information": [ { "code": "A9601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj velmanase alfa-tycv 1 mg", "code_information": [ { "code": "J0217", "type": "HCPCS" }, { "code": "10122-0180-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, artesunate, 1mg", "code_information": [ { "code": "J0391", "type": "HCPCS" }, { "code": "73607-0011-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Inj, carmustine (accord)", "code_information": [ { "code": "J9052", "type": "HCPCS" }, { "code": "16729-0545-63", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj glofitamab gxbm, 2.5 mg", "code_information": [ { "code": "J9286", "type": "HCPCS" }, { "code": "50242-0125-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2.5, "type": "ML" } }, { "description": "Inj ronzanolixizum-noli 1 mg", "code_information": [ { "code": "J9333", "type": "HCPCS" }, { "code": "50474-0980-79", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Dexmedetomidine film, 1 mcg", "code_information": [ { "code": "J1105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj efgart-alfa 2mg hya-qvfc", "code_information": [ { "code": "J9334", "type": "HCPCS" }, { "code": "73475-3102-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5.6, "type": "ML" } }, { "description": "Dexrazoxane hcl injection", "code_information": [ { "code": "J1190", "type": "HCPCS" }, { "code": "00143-9247-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Sargramostim injection", "code_information": [ { "code": "J2820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amphotericin b liposome inj", "code_information": [ { "code": "J0289", "type": "HCPCS" }, { "code": "00469-3051-30", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Rasburicase", "code_information": [ { "code": "J2783", "type": "HCPCS" }, { "code": "00024-5150-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Dactinomycin injection", "code_information": [ { "code": "J9120", "type": "HCPCS" }, { "code": "39822-2100-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Naltrexone, depot form", "code_information": [ { "code": "J2315", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m exametazime", "code_information": [ { "code": "A9521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "In111 ibritumomab, dx", "code_information": [ { "code": "A9542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "In111 oxyquinoline", "code_information": [ { "code": "A9547", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "In111 pentetate", "code_information": [ { "code": "A9548", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m bicisate", "code_information": [ { "code": "A9557", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Technetium tc99m arcitumomab", "code_information": [ { "code": "A9568", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Technetium tc-99m auto wbc", "code_information": [ { "code": "A9569", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Indium in-111 auto wbc", "code_information": [ { "code": "A9570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Indium in-111 pentetreotide", "code_information": [ { "code": "A9572", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Iodine i-123 iobenguane", "code_information": [ { "code": "A9582", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Iodine i-123 ioflupane", "code_information": [ { "code": "A9584", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, pemrydi rtu, 10 mg", "code_information": [ { "code": "J9324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj cefazolin sodium, hikma", "code_information": [ { "code": "J0688", "type": "HCPCS" }, { "code": "00143-9139-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, daptomycin (xellia)", "code_information": [ { "code": "J0873", "type": "HCPCS" }, { "code": "70594-0053-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, glycopyrrolate, 0.1 mg", "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "00517-4601-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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, bumetanide, 0.5 mg", "code_information": [ { "code": "J1939", "type": "HCPCS" }, { "code": "00641-6284-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, sezaby, 1 mg", "code_information": [ { "code": "J2561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj fluphenazine hcl 1.25 mg", "code_information": [ { "code": "J2679", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Leuprolide acetate /3.75 mg", "code_information": [ { "code": "J1950", "type": "HCPCS" }, { "code": "00074-2108-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, hydroxocobalamin", "code_information": [ { "code": "J3425", "type": "HCPCS" }, { "code": "00591-2888-30", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Aldesleukin injection", "code_information": [ { "code": "J9015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Goserelin acetate implant", "code_information": [ { "code": "J9202", "type": "HCPCS" }, { "code": "70720-0950-36", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Carmustine injection", "code_information": [ { "code": "J9050", "type": "HCPCS" }, { "code": "00781-3474-32", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, magtrace per study dose", "code_information": [ { "code": "A9697", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Daunorubicin injection", "code_information": [ { "code": "J9150", "type": "HCPCS" }, { "code": "00143-9551-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Nelarabine injection", "code_information": [ { "code": "J9261", "type": "HCPCS" }, { "code": "00078-0683-06", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Floxuridine injection", "code_information": [ { "code": "J9200", "type": "HCPCS" }, { "code": "00143-9270-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj melpha hydroch nos 50 mg", "code_information": [ { "code": "J9245", "type": "HCPCS" }, { "code": "23155-0355-41", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Pegaspargase injection", "code_information": [ { "code": "J9266", "type": "HCPCS" }, { "code": "00944-3810-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Pentostatin injection", "code_information": [ { "code": "J9268", "type": "HCPCS" }, { "code": "00409-0801-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Thiotepa injection", "code_information": [ { "code": "J9340", "type": "HCPCS" }, { "code": "00143-9292-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Porfimer sodium injection", "code_information": [ { "code": "J9600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj cladribine per 1 mg", "code_information": [ { "code": "J9065", "type": "HCPCS" }, { "code": "00143-9871-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Mitoxantrone hydrochl / 5 mg", "code_information": [ { "code": "J9293", "type": "HCPCS" }, { "code": "00703-4680-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 12.5, "type": "ML" } }, { "description": "Synvisc or synvisc-one", "code_information": [ { "code": "J7325", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Euflexxa inj per dose", "code_information": [ { "code": "J7323", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthovisc inj per dose", "code_information": [ { "code": "J7324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Azathioprine parenteral", "code_information": [ { "code": "J7501", "type": "HCPCS" }, { "code": "00143-9566-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Lymphocyte immune globulin", "code_information": [ { "code": "J7504", "type": "HCPCS" }, { "code": "00009-7224-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Alpha 1 proteinase inhibitor", "code_information": [ { "code": "J0256", "type": "HCPCS" }, { "code": "00944-2814-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection,onabotulinumtoxina", "code_information": [ { "code": "J0585", "type": "HCPCS" }, { "code": "00023-1145-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Cytomegalovirus imm iv /vial", "code_information": [ { "code": "J0850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor viii", "code_information": [ { "code": "J7190", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor viii recombinant nos", "code_information": [ { "code": "J7192", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor ix complex", "code_information": [ { "code": "J7194", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anti-inhibitor", "code_information": [ { "code": "J7198", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor ix non-recombinant", "code_information": [ { "code": "J7193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor ix recombinant nos", "code_information": [ { "code": "J7195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gammagard liquid injection", "code_information": [ { "code": "J1569", "type": "HCPCS" }, { "code": "00944-2700-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Hepagam b im injection", "code_information": [ { "code": "J1571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Flebogamma injection", "code_information": [ { "code": "J1572", "type": "HCPCS" }, { "code": "61953-0004-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Albumin (human), 5%, 250 ml", "code_information": [ { "code": "P9045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection glatiramer acetate", "code_information": [ { "code": "J1595", "type": "HCPCS" }, { "code": "00378-6960-93", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Hepagam b intravenous, inj", "code_information": [ { "code": "J1573", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Protein c concentrate", "code_information": [ { "code": "J2724", "type": "HCPCS" }, { "code": "00944-4177-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Supprelin la implant", "code_information": [ { "code": "J9226", "type": "HCPCS" }, { "code": "67979-0002-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "I131 iodide sol, rx", "code_information": [ { "code": "A9530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Temsirolimus injection", "code_information": [ { "code": "J9330", "type": "HCPCS" }, { "code": "16729-0223-61", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Busulfan injection", "code_information": [ { "code": "J0594", "type": "HCPCS" }, { "code": "00409-1112-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Verteporfin injection", "code_information": [ { "code": "J3396", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Octreotide injection, depot", "code_information": [ { "code": "J2353", "type": "HCPCS" }, { "code": "00078-0790-61", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Antihemophilic viii/vwf comp", "code_information": [ { "code": "J7186", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Valrubicin injection", "code_information": [ { "code": "J9357", "type": "HCPCS" }, { "code": "24201-0101-04", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj iron dextran", "code_information": [ { "code": "J1750", "type": "HCPCS" }, { "code": "00023-6082-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Antithrombin iii injection", "code_information": [ { "code": "J7197", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xyntha inj", "code_information": [ { "code": "J7185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Edetate calcium disodium inj", "code_information": [ { "code": "J0600", "type": "HCPCS" }, { "code": "49452-2697-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "GM" } }, { "description": "Abobotulinumtoxina", "code_information": [ { "code": "J0586", "type": "HCPCS" }, { "code": "15054-0500-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Sm 153 lexidronam", "code_information": [ { "code": "A9604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Degarelix injection", "code_information": [ { "code": "J9155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ferumoxytol, non-esrd", "code_information": [ { "code": "Q0138", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Canakinumab injection", "code_information": [ { "code": "J0638", "type": "HCPCS" }, { "code": "00078-0734-61", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Hizentra injection", "code_information": [ { "code": "J1559", "type": "HCPCS" }, { "code": "44206-0451-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Imuglucerase injection", "code_information": [ { "code": "J1786", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Olanzapine long-acting inj", "code_information": [ { "code": "J2358", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Collagenase, clost hist inj", "code_information": [ { "code": "J0775", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Wilate injection", "code_information": [ { "code": "J7183", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Belimumab injection", "code_information": [ { "code": "J0490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lumizyme injection", "code_information": [ { "code": "J0221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Glassia injection", "code_information": [ { "code": "J0257", "type": "HCPCS" }, { "code": "00944-2884-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Factor xiii anti-hem factor", "code_information": [ { "code": "J7180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gel-one", "code_information": [ { "code": "J7326", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aflibercept injection", "code_information": [ { "code": "J0178", "type": "HCPCS" }, { "code": "61755-0005-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.05, "type": "ML" } }, { "description": "Imported lipodox inj", "code_information": [ { "code": "Q2049", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Eribulin mesylate injection", "code_information": [ { "code": "J9179", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Centruroides immune f(ab)", "code_information": [ { "code": "J0716", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Calcitonin salmon injection", "code_information": [ { "code": "J0630", "type": "HCPCS" }, { "code": "24201-0400-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Fiasp for insulin pump use", "code_information": [ { "code": "J1811", "type": "HCPCS" }, { "code": "00169-3201-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 ruxience, 10 mg", "code_information": [ { "code": "Q5119", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluoroestradiol f 18", "code_information": [ { "code": "A9591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. xembify, 100 mg", "code_information": [ { "code": "J1558", "type": "HCPCS" }, { "code": "13533-0810-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Mitomycin instillation", "code_information": [ { "code": "J9281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., evomela, 1 mg", "code_information": [ { "code": "J9246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sacituzumab govitecan-hziy", "code_information": [ { "code": "J9317", "type": "HCPCS" }, { "code": "55135-0132-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. isatuximab-irfc 10 mg", "code_information": [ { "code": "J9227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. avsola, 10 mg", "code_information": [ { "code": "Q5121", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj ontruzant 10 mg", "code_information": [ { "code": "Q5112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Copper cu 64 dotatate diag", "code_information": [ { "code": "A9592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj belantamab mafodot blmf", "code_information": [ { "code": "J9037", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor xiii recomb a-subunit", "code_information": [ { "code": "J7181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Monovisc inj per dose", "code_information": [ { "code": "J7327", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rolapitant, oral, 1mg", "code_information": [ { "code": "J8670", "type": "HCPCS" }, { "code": "69656-0101-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, alemtuzumab", "code_information": [ { "code": "J0202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, zarxio", "code_information": [ { "code": "Q5101", "type": "HCPCS" }, { "code": "61314-0304-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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, dalbavancin", "code_information": [ { "code": "J0875", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ceftazidime and avibactam", "code_information": [ { "code": "J0714", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hyqvia 100mg immuneglobulin", "code_information": [ { "code": "J1575", "type": "HCPCS" }, { "code": "00944-2510-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 26.25, "type": "ML" } }, { "description": "Factor viii recomb obizur", "code_information": [ { "code": "J7188", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Penicillin g benzathine inj", "code_information": [ { "code": "J0561", "type": "HCPCS" }, { "code": "54868-0753-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Dimethyl sulfoxide 50% 50 ml", "code_information": [ { "code": "J1212", "type": "HCPCS" }, { "code": "10106-9224-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Penicillin g procaine inj", "code_information": [ { "code": "J2510", "type": "HCPCS" }, { "code": "60793-0130-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Factor viii pegylated recomb", "code_information": [ { "code": "J7207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor viii nuwiq recomb 1iu", "code_information": [ { "code": "J7209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, inflectra", "code_information": [ { "code": "Q5103", "type": "HCPCS" }, { "code": "00069-0809-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Foscarnet sodium injection", "code_information": [ { "code": "J1455", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gamma globulin 1 cc inj", "code_information": [ { "code": "J1460", "type": "HCPCS" }, { "code": "13533-0335-04", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Gamma globulin > 10 cc inj", "code_information": [ { "code": "J1560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Interferon beta-1a inj", "code_information": [ { "code": "J1826", "type": "HCPCS" }, { "code": "59627-0111-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "EA" } }, { "description": "Minocycline hydrochloride", "code_information": [ { "code": "J2265", "type": "HCPCS" }, { "code": "70842-0160-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Factor viii recomb novoeight", "code_information": [ { "code": "J7182", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, factor x, (human), 1iu", "code_information": [ { "code": "J7175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Argatroban nonesrd use 1mg", "code_information": [ { "code": "J0883", "type": "HCPCS" }, { "code": "00078-0930-61", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2.5, "type": "ML" } }, { "description": "Inj., bendeka 1 mg", "code_information": [ { "code": "J9034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immune globulin, powder", "code_information": [ { "code": "J1566", "type": "HCPCS" }, { "code": "00944-2656-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Quinupristin/dalfopristin", "code_information": [ { "code": "J2770", "type": "HCPCS" }, { "code": "61570-0260-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Infliximab not biosimil 10mg", "code_information": [ { "code": "J1745", "type": "HCPCS" }, { "code": "57894-0030-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Doxorubicin inj 10mg", "code_information": [ { "code": "Q2050", "type": "HCPCS" }, { "code": "00338-0063-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Aminolevulinic acid hcl top", "code_information": [ { "code": "J7308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tenecteplase injection", "code_information": [ { "code": "J3101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rsv mab im 50mg", "code_information": [ { "code": "90378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, inclisiran, 1 mg", "code_information": [ { "code": "J1306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reteplase injection", "code_information": [ { "code": "J2993", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tacrolimus injection", "code_information": [ { "code": "J7525", "type": "HCPCS" }, { "code": "00469-3016-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 tezepelumab-ekko, 1mg", "code_information": [ { "code": "J2356", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, vutrisiran, 1 mg", "code_information": [ { "code": "J0225", "type": "HCPCS" }, { "code": "71336-1003-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj efgartigimod 2mg", "code_information": [ { "code": "J9332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arsenic trioxide injection", "code_information": [ { "code": "J9017", "type": "HCPCS" }, { "code": "10106-0061-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj risankizumab-rzaa 1 mg", "code_information": [ { "code": "J2327", "type": "HCPCS" }, { "code": "00074-5015-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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., triptorelin xr 3.75 mg", "code_information": [ { "code": "J3316", "type": "HCPCS" }, { "code": "24338-0150-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. byooviz, 0.1 mg", "code_information": [ { "code": "Q5124", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, rimabotulinumtoxinb", "code_information": [ { "code": "J0587", "type": "HCPCS" }, { "code": "10454-0710-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Argatroban nonesrd (accord)", "code_information": [ { "code": "J0891", "type": "HCPCS" }, { "code": "16729-0430-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Argatroban nonesrd (auromed)", "code_information": [ { "code": "J0898", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amphotericin b lipid complex", "code_information": [ { "code": "J0287", "type": "HCPCS" }, { "code": "57665-0101-41", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj glucagon hcl, fresenius", "code_information": [ { "code": "J1611", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, bortezomib, dr. reddy's", "code_information": [ { "code": "J9046", "type": "HCPCS" }, { "code": "43598-0865-60", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, bortezomib freseniuskab", "code_information": [ { "code": "J9048", "type": "HCPCS" }, { "code": "63323-0721-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj inotuzumab ozogam 0.1 mg", "code_information": [ { "code": "J9229", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., guselkumab, 1 mg", "code_information": [ { "code": "J1628", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., copanlisib, 1 mg", "code_information": [ { "code": "J9057", "type": "HCPCS" }, { "code": "50419-0385-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Baclofen 10 mg injection", "code_information": [ { "code": "J0475", "type": "HCPCS" }, { "code": "14789-0161-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Cidofovir injection", "code_information": [ { "code": "J0740", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj cuvitru, 100 mg", "code_information": [ { "code": "J1555", "type": "HCPCS" }, { "code": "00944-2850-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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, renflexis", "code_information": [ { "code": "Q5104", "type": "HCPCS" }, { "code": "00006-4305-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj estrogen conjugate 25 mg", "code_information": [ { "code": "J1410", "type": "HCPCS" }, { "code": "00046-0749-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, afstyla, 1 i.u.", "code_information": [ { "code": "J7210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ibutilide fumarate injection", "code_information": [ { "code": "J1742", "type": "HCPCS" }, { "code": "00009-3794-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Idursulfase injection", "code_information": [ { "code": "J1743", "type": "HCPCS" }, { "code": "54092-0700-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 3, "type": "ML" } }, { "description": "Inj., fibryga, 1 mg", "code_information": [ { "code": "J7177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj alymsys 10 mg", "code_information": [ { "code": "Q5126", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Leuprolide inj, camcevi, 1mg", "code_information": [ { "code": "J1952", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, lanreotide, (cipla) 1mg", "code_information": [ { "code": "J1932", "type": "HCPCS" }, { "code": "69097-0870-67", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Fluciclovine f-18", "code_information": [ { "code": "A9588", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluorodopa f-18 diag per mci", "code_information": [ { "code": "A9602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lutetium lu 177 vipivotide", "code_information": [ { "code": "A9607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gallium locametz 1 millicuri", "code_information": [ { "code": "A9800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gallium ga-68", "code_information": [ { "code": "A9587", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj nivol relatlimab 3mg/1mg", "code_information": [ { "code": "J9298", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vonvendi inj 1 iu vwf:rco", "code_information": [ { "code": "J7179", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lutetium lu 177 dotatat ther", "code_information": [ { "code": "A9513", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj luxturna 1 billion vec g", "code_information": [ { "code": "J3398", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Capsaicin 8% patch", "code_information": [ { "code": "J7336", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Buprenorph xr 100 mg or less", "code_information": [ { "code": "Q9991", "type": "HCPCS" }, { "code": "12496-0100-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Makena, 10 mg", "code_information": [ { "code": "J1726", "type": "HCPCS" }, { "code": "64011-0247-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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, kovaltry, 1 i.u.", "code_information": [ { "code": "J7211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Epoetin beta non esrd", "code_information": [ { "code": "J0888", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Testosterone undecanoate 1mg", "code_information": [ { "code": "J3145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Genvisc 850, inj, 1mg", "code_information": [ { "code": "J7320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fludarabine phosphate inj", "code_information": [ { "code": "J9185", "type": "HCPCS" }, { "code": "00703-4852-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Peng benzathine/procaine inj", "code_information": [ { "code": "J0558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiesse injection", "code_information": [ { "code": "Q2026", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, sculptra, 0.5mg", "code_information": [ { "code": "Q2028", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj retacrit esrd on dialysi", "code_information": [ { "code": "Q5105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj retacrit non-esrd use", "code_information": [ { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1305-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 fosnetupitant, palonoset", "code_information": [ { "code": "J1454", "type": "HCPCS" }, { "code": "69639-0102-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, fulvestrant (teva)", "code_information": [ { "code": "J9393", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, fulvestrant (fresenius)", "code_information": [ { "code": "J9394", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Antithymocyte globuln rabbit", "code_information": [ { "code": "J7511", "type": "HCPCS" }, { "code": "58468-0080-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj pemetrexed (teva) 10mg", "code_information": [ { "code": "J9314", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thyrotropin injection", "code_information": [ { "code": "J3240", "type": "HCPCS" }, { "code": "58468-0030-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Inj, elahere, 1 mg", "code_information": [ { "code": "J9063", "type": "HCPCS" }, { "code": "72903-0853-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, tremelimumab-actl, 1 mg", "code_information": [ { "code": "J9347", "type": "HCPCS" }, { "code": "00310-4505-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1.25, "type": "ML" } }, { "description": "Inj teclistamab cqyv 0.5 mg", "code_information": [ { "code": "J9380", "type": "HCPCS" }, { "code": "57894-0449-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 3, "type": "ML" } }, { "description": "Inj teplizumab mzwv 5 mcg", "code_information": [ { "code": "J9381", "type": "HCPCS" }, { "code": "73650-0316-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj olipudase alfa-rpcp 1mg", "code_information": [ { "code": "J0218", "type": "HCPCS" }, { "code": "58468-0050-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj eflapegrastim-xnst 0.1mg", "code_information": [ { "code": "J1449", "type": "HCPCS" }, { "code": "76961-0101-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.6, "type": "ML" } }, { "description": "Inj, spesolimab-sbzo, 1 mg", "code_information": [ { "code": "J1747", "type": "HCPCS" }, { "code": "00597-0035-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 7.5, "type": "ML" } }, { "description": "Inj, cimerli, 0.1 mg", "code_information": [ { "code": "Q5128", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, fylnetra, 0.5 mg", "code_information": [ { "code": "Q5130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj sodium thiosulfate 100mg", "code_information": [ { "code": "J0208", "type": "HCPCS" }, { "code": "60267-0705-50", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, fulvestrant", "code_information": [ { "code": "J9395", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Triptorelin pamoate", "code_information": [ { "code": "J3315", "type": "HCPCS" }, { "code": "00023-5902-04", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj pemetrexed, hospira 10mg", "code_information": [ { "code": "J9294", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj risperdal consta, 0.5 mg", "code_information": [ { "code": "J2794", "type": "HCPCS" }, { "code": "50458-0306-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Natalizumab injection", "code_information": [ { "code": "J2323", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj pemetrexed (accord) 10mg", "code_information": [ { "code": "J9296", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, stimufend, 0.5 mg", "code_information": [ { "code": "Q5127", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, ado-trastuzumab emt 1mg", "code_information": [ { "code": "J9354", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prothrombin complex kcentra", "code_information": [ { "code": "J7168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rabies ig im/sc", "code_information": [ { "code": "90375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rabies ig heat treated", "code_information": [ { "code": "90376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Varicella-zoster ig im", "code_information": [ { "code": "90396", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rabies vaccine id", "code_information": [ { "code": "90676", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, panzyga, 500 mg", "code_information": [ { "code": "J1576", "type": "HCPCS" }, { "code": "00069-1011-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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, invega hafyera/trinza", "code_information": [ { "code": "J2427", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, ixinity, 1 i.u.", "code_information": [ { "code": "J7213", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj ublituximab-xiiy, 1 mg", "code_information": [ { "code": "J2329", "type": "HCPCS" }, { "code": "73150-0150-06", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 6, "type": "ML" } }, { "description": "Inj mosunetuzumab-axgb, 1 mg", "code_information": [ { "code": "J9350", "type": "HCPCS" }, { "code": "50242-0142-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, bendamustine, 1 mg", "code_information": [ { "code": "J9056", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, lenacapavir, 1 mg", "code_information": [ { "code": "J1961", "type": "HCPCS" }, { "code": "61958-3002-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1.5, "type": "ML" } }, { "description": "Inj pemetrexed ditromethamin", "code_information": [ { "code": "J9323", "type": "HCPCS" }, { "code": "00409-1060-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, lecanemab-irmb, 1 mg", "code_information": [ { "code": "J0174", "type": "HCPCS" }, { "code": "62856-0212-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, pegcetacoplan, 1mg", "code_information": [ { "code": "J2781", "type": "HCPCS" }, { "code": "73606-0020-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.1, "type": "ML" } }, { "description": "Inj, vegzelma, 10 mg", "code_information": [ { "code": "Q5129", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, fosaprepitant (teva)", "code_information": [ { "code": "J1456", "type": "HCPCS" }, { "code": "00591-4385-79", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Factor ix idelvion inj", "code_information": [ { "code": "J7202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, fulphila", "code_information": [ { "code": "Q5108", "type": "HCPCS" }, { "code": "67457-0833-06", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.6, "type": "ML" } }, { "description": "Inj, durolane 1 mg", "code_information": [ { "code": "J7318", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., meropenem, vaborbactam", "code_information": [ { "code": "J2186", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., aristada initio, 1 mg", "code_information": [ { "code": "J1943", "type": "HCPCS" }, { "code": "65757-0500-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2.4, "type": "ML" } }, { "description": "Inj., patisiran, 0.1 mg", "code_information": [ { "code": "J0222", "type": "HCPCS" }, { "code": "71336-1000-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., perseris, 0.5 mg", "code_information": [ { "code": "J2798", "type": "HCPCS" }, { "code": "12496-0090-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj mogamulizumab-kpkc, 1 mg", "code_information": [ { "code": "J9204", "type": "HCPCS" }, { "code": "42747-0761-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., plazomicin, 5 mg", "code_information": [ { "code": "J0291", "type": "HCPCS" }, { "code": "69097-0820-96", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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., rituximab, 10 mg", "code_information": [ { "code": "J9312", "type": "HCPCS" }, { "code": "50242-0051-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, burosumab-twza 1m", "code_information": [ { "code": "J0584", "type": "HCPCS" }, { "code": "42747-0102-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 crotalidae im f(ab')2 eq", "code_information": [ { "code": "J0841", "type": "HCPCS" }, { "code": "66621-0790-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., ibalizumab-uiyk, 10 mg", "code_information": [ { "code": "J1746", "type": "HCPCS" }, { "code": "62064-0122-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1.33, "type": "ML" } }, { "description": "Nivestym", "code_information": [ { "code": "Q5110", "type": "HCPCS" }, { "code": "00069-0291-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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, udenyca 0.5 mg", "code_information": [ { "code": "Q5111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, trivisc 1 mg", "code_information": [ { "code": "J7329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj andexxa, 10 mg", "code_information": [ { "code": "J7169", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rabies ig ht&sol human im/sc", "code_information": [ { "code": "90377", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj cyclophosphamd auromedic", "code_information": [ { "code": "J9071", "type": "HCPCS" }, { "code": "55150-0270-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2.5, "type": "ML" } }, { "description": "Inj tisotu vedotin-tftv, 1mg", "code_information": [ { "code": "J9273", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj lon tesirin-lpyl 0.075mg", "code_information": [ { "code": "J9359", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj plasminogen tvmh 1mg", "code_information": [ { "code": "J2998", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Agalsidase beta injection", "code_information": [ { "code": "J0180", "type": "HCPCS" }, { "code": "58468-0040-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Laronidase injection", "code_information": [ { "code": "J1931", "type": "HCPCS" }, { "code": "58468-0070-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. pemetrexed nos 10mg", "code_information": [ { "code": "J9305", "type": "HCPCS" }, { "code": "00002-7623-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Cetuximab injection", "code_information": [ { "code": "J9055", "type": "HCPCS" }, { "code": "66733-0948-23", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Leuprolide acetate suspnsion", "code_information": [ { "code": "J9217", "type": "HCPCS" }, { "code": "00074-3346-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Procainamide hcl injection", "code_information": [ { "code": "J2690", "type": "HCPCS" }, { "code": "00409-1902-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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., retisert, 0.01 mg", "code_information": [ { "code": "J7311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abatacept injection", "code_information": [ { "code": "J0129", "type": "HCPCS" }, { "code": "00003-2187-13", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Ranibizumab injection", "code_information": [ { "code": "J2778", "type": "HCPCS" }, { "code": "50242-0080-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.05, "type": "ML" } }, { "description": "Panitumumab injection", "code_information": [ { "code": "J9303", "type": "HCPCS" }, { "code": "55513-0954-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Eculizumab injection", "code_information": [ { "code": "J1300", "type": "HCPCS" }, { "code": "25682-0001-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Lanreotide injection", "code_information": [ { "code": "J1930", "type": "HCPCS" }, { "code": "15054-1060-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.2, "type": "ML" } }, { "description": "Buprenorphine xr over 100 mg", "code_information": [ { "code": "Q9992", "type": "HCPCS" }, { "code": "12496-0300-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1.5, "type": "ML" } }, { "description": "Ixabepilone injection", "code_information": [ { "code": "J9207", "type": "HCPCS" }, { "code": "70020-1910-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj sirolimus prot part 1 mg", "code_information": [ { "code": "J9331", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., treanda 1 mg", "code_information": [ { "code": "J9033", "type": "HCPCS" }, { "code": "16729-0251-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, abilify asimtufii, 1 mg", "code_information": [ { "code": "J0402", "type": "HCPCS" }, { "code": "59148-0102-80", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2.4, "type": "ML" } }, { "description": "Inj, amisulpride, 1 mg", "code_information": [ { "code": "J0184", "type": "HCPCS" }, { "code": "71390-0125-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj epcoritamab-bysp 0.16 mg", "code_information": [ { "code": "J9321", "type": "HCPCS" }, { "code": "82705-0002-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.8, "type": "ML" } }, { "description": "C-1 esterase, cinryze", "code_information": [ { "code": "J0598", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Plerixafor injection", "code_information": [ { "code": "J2562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Temozolomide injection", "code_information": [ { "code": "J9328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, invega sustenna, 1 mg", "code_information": [ { "code": "J2426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dexamethasone intra implant", "code_information": [ { "code": "J7312", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., emicizumab-kxwh 0.5 mg", "code_information": [ { "code": "J7170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Telavancin injection", "code_information": [ { "code": "J3095", "type": "HCPCS" }, { "code": "62847-0001-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Pralatrexate injection", "code_information": [ { "code": "J9307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ofatumumab injection", "code_information": [ { "code": "J9302", "type": "HCPCS" }, { "code": "00078-0669-13", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Ustekinumab sub cu inj, 1 mg", "code_information": [ { "code": "J3357", "type": "HCPCS" }, { "code": "57894-0060-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj tofersen intrathec 1 mg", "code_information": [ { "code": "J1304", "type": "HCPCS" }, { "code": "64406-0109-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 15, "type": "ML" } }, { "description": "Ecallantide injection", "code_information": [ { "code": "J1290", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tocilizumab injection", "code_information": [ { "code": "J3262", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, uzedy, 1 mg", "code_information": [ { "code": "J2799", "type": "HCPCS" }, { "code": "51759-0305-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.14, "type": "ML" } }, { "description": "Inj, rezafungin, 1 mg", "code_information": [ { "code": "J0349", "type": "HCPCS" }, { "code": "70842-0240-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "C-1 esterase, berinert", "code_information": [ { "code": "J0597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gammaplex injection", "code_information": [ { "code": "J1557", "type": "HCPCS" }, { "code": "64208-8234-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Velaglucerase alfa", "code_information": [ { "code": "J3385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Denosumab injection", "code_information": [ { "code": "J0897", "type": "HCPCS" }, { "code": "55513-0710-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Sipuleucel-t auto cd54+", "code_information": [ { "code": "Q2043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Crotalidae poly immune fab", "code_information": [ { "code": "J0840", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cabazitaxel injection", "code_information": [ { "code": "J9043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Incobotulinumtoxin a", "code_information": [ { "code": "J0588", "type": "HCPCS" }, { "code": "00259-1605-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, retifanlimab-dlwr, 1 mg", "code_information": [ { "code": "J9345", "type": "HCPCS" }, { "code": "50881-0006-03", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Pegloticase injection", "code_information": [ { "code": "J2507", "type": "HCPCS" }, { "code": "75987-0080-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Ipilimumab injection", "code_information": [ { "code": "J9228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj allopurinol sodium 1 mg", "code_information": [ { "code": "J0206", "type": "HCPCS" }, { "code": "00143-9533-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Belatacept injection", "code_information": [ { "code": "J0485", "type": "HCPCS" }, { "code": "00003-0371-13", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Brentuximab vedotin inj", "code_information": [ { "code": "J9042", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, taliglucerase alfa 10 u", "code_information": [ { "code": "J3060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, carfilzomib, 1 mg", "code_information": [ { "code": "J9047", "type": "HCPCS" }, { "code": "76075-0101-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, ziv-aflibercept, 1mg", "code_information": [ { "code": "J9400", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, omacetaxine mep, 0.01mg", "code_information": [ { "code": "J9262", "type": "HCPCS" }, { "code": "63459-0177-14", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. jivi 1 iu", "code_information": [ { "code": "J7208", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Omalizumab injection", "code_information": [ { "code": "J2357", "type": "HCPCS" }, { "code": "50242-0040-62", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Aminolevulinic acid, 10% gel", "code_information": [ { "code": "J7345", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj daunorubicin, cytarabine", "code_information": [ { "code": "J9153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., cemiplimab-rwlc, 1 mg", "code_information": [ { "code": "J9119", "type": "HCPCS" }, { "code": "61755-0008-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 7, "type": "ML" } }, { "description": "Inj., lumoxiti, 0.01 mg", "code_information": [ { "code": "J9313", "type": "HCPCS" }, { "code": "00310-4700-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., tildrakizumab, 1 mg", "code_information": [ { "code": "J3245", "type": "HCPCS" }, { "code": "47335-0177-95", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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. tagraxofusp-erzs 10 mcg", "code_information": [ { "code": "J9269", "type": "HCPCS" }, { "code": "72187-0401-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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., emapalumab-lzsg, 1 mg", "code_information": [ { "code": "J9210", "type": "HCPCS" }, { "code": "66658-0501-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., omadacycline, 1 mg", "code_information": [ { "code": "J0121", "type": "HCPCS" }, { "code": "71715-0001-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., ravulizumab-cwvz 10 mg", "code_information": [ { "code": "J1303", "type": "HCPCS" }, { "code": "25682-0022-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. belrapzo/bendamustine", "code_information": [ { "code": "J9036", "type": "HCPCS" }, { "code": "10019-0079-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. herceptin hylecta, 10mg", "code_information": [ { "code": "J9356", "type": "HCPCS" }, { "code": "50242-0077-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Somatropin injection", "code_information": [ { "code": "J2941", "type": "HCPCS" }, { "code": "00002-7335-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Carbidopa levodopa ent 100ml", "code_information": [ { "code": "J7340", "type": "HCPCS" }, { "code": "00074-3012-07", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. romosozumab-aqqg 1 mg", "code_information": [ { "code": "J3111", "type": "HCPCS" }, { "code": "55513-0880-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1.17, "type": "ML" } }, { "description": "Inj., yutiq, 0.01 mg", "code_information": [ { "code": "J7314", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj mvasi 10 mg", "code_information": [ { "code": "Q5107", "type": "HCPCS" }, { "code": "55513-0206-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., kanjinti, 10 mg", "code_information": [ { "code": "Q5117", "type": "HCPCS" }, { "code": "55513-0132-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, polatuzumab vedotin 1mg", "code_information": [ { "code": "J9309", "type": "HCPCS" }, { "code": "50242-0103-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Oral busulfan", "code_information": [ { "code": "J8510", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj truxima 10 mg", "code_information": [ { "code": "Q5115", "type": "HCPCS" }, { "code": "63459-0103-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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., triluron, 1 mg", "code_information": [ { "code": "J7332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, brolucizumab-dbll, 1 mg", "code_information": [ { "code": "J0179", "type": "HCPCS" }, { "code": "00078-0827-60", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.05, "type": "ML" } }, { "description": "Inj ogivri 10 mg", "code_information": [ { "code": "Q5114", "type": "HCPCS" }, { "code": "67457-0845-50", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj givosiran 0.5 mg", "code_information": [ { "code": "J0223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj pegfilgrastim-bmez 0.5mg", "code_information": [ { "code": "Q5120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj luspatercept-aamt 0.25mg", "code_information": [ { "code": "J0896", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., zirabev, 10 mg", "code_information": [ { "code": "Q5118", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj herzuma 10 mg", "code_information": [ { "code": "Q5113", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., trazimera, 10 mg", "code_information": [ { "code": "Q5116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj bimatoprost itc imp1mcg", "code_information": [ { "code": "J7351", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj fam-trastu deru-nxki 1mg", "code_information": [ { "code": "J9358", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj recombin esperoct per iu", "code_information": [ { "code": "J7204", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. teprotumumab-trbw 10 mg", "code_information": [ { "code": "J3241", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. eptinezumab-jjmr 1 mg", "code_information": [ { "code": "J3032", "type": "HCPCS" }, { "code": "67386-0130-51", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 xipere 1 mg", "code_information": [ { "code": "J3299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj crizanlizumab-tmca 5mg", "code_information": [ { "code": "J0791", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. cetirizine hcl 0.5mg", "code_information": [ { "code": "J1201", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj imip 4 cilas 4 releb 2mg", "code_information": [ { "code": "J0742", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj enfort vedo-ejfv 0.25mg", "code_information": [ { "code": "J9177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., tafasitamab-cxix", "code_information": [ { "code": "J9349", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. infugem, 100 mg", "code_information": [ { "code": "J9198", "type": "HCPCS" }, { "code": "62756-0008-60", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 130, "type": "ML" } }, { "description": "Inj. fe derisomaltose 10 mg", "code_information": [ { "code": "J1437", "type": "HCPCS" }, { "code": "73594-9310-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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. lurbinectedin, 0.1 mg", "code_information": [ { "code": "J9223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pertuzu, trastuzu, 10 mg", "code_information": [ { "code": "J9316", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. asceniv", "code_information": [ { "code": "J1554", "type": "HCPCS" }, { "code": "69800-0250-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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. inebilizumab-cdon, 1 mg", "code_information": [ { "code": "J1823", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Afamelanotide implant, 1 mg", "code_information": [ { "code": "J7352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, nyvepria", "code_information": [ { "code": "Q5122", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. lumasiran, 0.5 mg", "code_information": [ { "code": "J0224", "type": "HCPCS" }, { "code": "71336-1002-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj. naxitamab-gqgk, 1 mg", "code_information": [ { "code": "J9348", "type": "HCPCS" }, { "code": "73042-0201-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Gallium ga-68 psma-11 ucsf", "code_information": [ { "code": "A9593", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gallium ga-68 psma-11, ucla", "code_information": [ { "code": "A9594", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. riabni, 10 mg", "code_information": [ { "code": "Q5123", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, cabote rilpivir 2mg 3mg", "code_information": [ { "code": "J0741", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, trilaciclib, 1mg", "code_information": [ { "code": "J1448", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, evinacumab-dgnb, 5mg", "code_information": [ { "code": "J1305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj. margetuximab-cmkb, 5 mg", "code_information": [ { "code": "J9353", "type": "HCPCS" }, { "code": "74527-0022-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 fensolvi 0.25 mg", "code_information": [ { "code": "J1951", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, granisetron, xr, 0.1 mg", "code_information": [ { "code": "J1627", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, cefiderocol, 10 mg", "code_information": [ { "code": "J0699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, oritavancin 10 mg", "code_information": [ { "code": "J2406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj romidepsin non-lyo 0.1mg", "code_information": [ { "code": "J9318", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj romidepsin lyophil 0.1mg", "code_information": [ { "code": "J9319", "type": "HCPCS" }, { "code": "59572-0984-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Piflu f-18, dia 1 millicurie", "code_information": [ { "code": "A9595", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, dostarlimab-gxly, 10 mg", "code_information": [ { "code": "J9272", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, amivantamab-vmjw", "code_information": [ { "code": "J9061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj aval alfa-nqpt 4mg", "code_information": [ { "code": "J0219", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj anifrolumab-fnia 1mg", "code_information": [ { "code": "J0491", "type": "HCPCS" }, { "code": "00310-3040-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj pegfilgrast ex bio 0.5mg", "code_information": [ { "code": "J2506", "type": "HCPCS" }, { "code": "55513-0190-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.6, "type": "ML" } }, { "description": "Inj, aspara, rylaze, 0.1 mg", "code_information": [ { "code": "J9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, aducanumab-avwa, 2 mg", "code_information": [ { "code": "J0172", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, susvimo 0.1 mg", "code_information": [ { "code": "J2779", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj ferric carboxymaltos 1mg", "code_information": [ { "code": "J1439", "type": "HCPCS" }, { "code": "00517-0650-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 15, "type": "ML" } }, { "description": "Inj. pemetrexed, 10 mg", "code_information": [ { "code": "J9304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gallium illuccix 1 millicure", "code_information": [ { "code": "A9596", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, sutimlimab-jome, 10 mg", "code_information": [ { "code": "J1302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, ruconest", "code_information": [ { "code": "J0596", "type": "HCPCS" }, { "code": "71274-0350-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, tebentafusp-tebn, 1 mcg", "code_information": [ { "code": "J9274", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, releuko 1 mcg", "code_information": [ { "code": "Q5125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Oral netupitant, palonosetro", "code_information": [ { "code": "J8655", "type": "HCPCS" }, { "code": "69639-0101-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, blinatumomab", "code_information": [ { "code": "J9039", "type": "HCPCS" }, { "code": "55513-0150-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj., iluvien, 0.01 mg", "code_information": [ { "code": "J7313", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, peramivir", "code_information": [ { "code": "J2547", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj ceftolozane tazobactam", "code_information": [ { "code": "J0695", "type": "HCPCS" }, { "code": "67919-0030-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, nivolumab", "code_information": [ { "code": "J9299", "type": "HCPCS" }, { "code": "00003-3734-13", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 24, "type": "ML" } }, { "description": "Inj, pasireotide long acting", "code_information": [ { "code": "J2502", "type": "HCPCS" }, { "code": "00078-0641-61", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, siltuximab", "code_information": [ { "code": "J2860", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, isavuconazonium", "code_information": [ { "code": "J1833", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Choline c-11", "code_information": [ { "code": "A9515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., aprepitant, 1 mg", "code_information": [ { "code": "J0185", "type": "HCPCS" }, { "code": "47426-0201-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 18, "type": "ML" } }, { "description": "Inj., benralizumab, 1 mg", "code_information": [ { "code": "J0517", "type": "HCPCS" }, { "code": "00310-1730-30", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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 rituximab, hyaluronidase", "code_information": [ { "code": "J9311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Factor ix recomb gly rebinyn", "code_information": [ { "code": "J7203", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj triamcinolone ace xr 1mg", "code_information": [ { "code": "J3304", "type": "HCPCS" }, { "code": "65250-0003-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Hymovis injection 1 mg", "code_information": [ { "code": "J7322", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj talimogene laherparepvec", "code_information": [ { "code": "J9325", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, mepolizumab, 1mg", "code_information": [ { "code": "J2182", "type": "HCPCS" }, { "code": "00173-0881-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj irinotecan liposome 1 mg", "code_information": [ { "code": "J9205", "type": "HCPCS" }, { "code": "15054-0043-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Injection, necitumumab, 1 mg", "code_information": [ { "code": "J9295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, daratumumab 10 mg", "code_information": [ { "code": "J9145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, elotuzumab, 1mg", "code_information": [ { "code": "J9176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj sebelipase alfa 1 mg", "code_information": [ { "code": "J2840", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection trabectedin 0.1mg", "code_information": [ { "code": "J9352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, reslizumab, 1mg", "code_information": [ { "code": "J2786", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, atezolizumab,10 mg", "code_information": [ { "code": "J9022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ustekinumab, iv inject, 1 mg", "code_information": [ { "code": "J3358", "type": "HCPCS" }, { "code": "57894-0054-27", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 26, "type": "ML" } }, { "description": "Inj, nusinersen, 0.1mg", "code_information": [ { "code": "J2326", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, bezlotoxumab, 10 mg", "code_information": [ { "code": "J0565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, avelumab, 10 mg", "code_information": [ { "code": "J9023", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj., durvalumab, 10 mg", "code_information": [ { "code": "J9173", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, edaravone, 1 mg", "code_information": [ { "code": "J1301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection, ocrelizumab, 1 mg", "code_information": [ { "code": "J2350", "type": "HCPCS" }, { "code": "50242-0150-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Gemtuzumab ozogamicin 0.1 mg", "code_information": [ { "code": "J9203", "type": "HCPCS" }, { "code": "00008-4510-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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": "Inj, faricimab-svoa, 0.1mg", "code_information": [ { "code": "J2777", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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) - Psychiatric", "code_information": [ { "code": "0124", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Detoxification", "code_information": [ { "code": "0126", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Psychiatric", "code_information": [ { "code": "0134", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Detoxification", "code_information": [ { "code": "0136", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Psychiatric", "code_information": [ { "code": "0144", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Detoxification", "code_information": [ { "code": "0146", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Psychiatric", "code_information": [ { "code": "0154", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Detoxification", "code_information": [ { "code": "0156", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Magnetic Resonance Technology (MRT) - Brain/Brainstem", "code_information": [ { "code": "0611", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - Spinal Cord/Spine", "code_information": [ { "code": "0612", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRI - Other", "code_information": [ { "code": "0614", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Head and Neck", "code_information": [ { "code": "0615", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Lower Extremities", "code_information": [ { "code": "0616", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Other", "code_information": [ { "code": "0618", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - Other", "code_information": [ { "code": "0619", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - Incident to Radiology", "code_information": [ { "code": "0621", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - Incident to Other Diagnostic Services", "code_information": [ { "code": "0622", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - Surgical Dressings", "code_information": [ { "code": "0623", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drugs requiring specific identification-general classification", "code_information": [ { "code": "0630", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Single Source Drug", "code_information": [ { "code": "0631", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Multiple Source Drug", "code_information": [ { "code": "0632", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Restrictive Prescription", "code_information": [ { "code": "0633", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Erythropoietin (EPO) less than 10,000 units", "code_information": [ { "code": "0634", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Erythropoietin (EPO) 10,000 or more units", "code_information": [ { "code": "0635", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Requiring Detailed Coding", "code_information": [ { "code": "0636", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_percentage": 50, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Self-administrable Drugs", "code_information": [ { "code": "0637", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Inpatient Respite Care", "code_information": [ { "code": "0655", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - General Inpatient Care (non-respite)", "code_information": [ { "code": "0656", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Recovery Room - General Classification", "code_information": [ { "code": "0710", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level I", "code_information": [ { "code": "0681", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level II", "code_information": [ { "code": "0682", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level III", "code_information": [ { "code": "0683", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level IV", "code_information": [ { "code": "0684", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Other", "code_information": [ { "code": "0689", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - General Classification", "code_information": [ { "code": "0690", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Visit Charge", "code_information": [ { "code": "0691", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Hourly Charge", "code_information": [ { "code": "0692", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Evaluation", "code_information": [ { "code": "0693", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Consultation and Education", "code_information": [ { "code": "0694", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Inpatient Care", "code_information": [ { "code": "0695", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Physician Services", "code_information": [ { "code": "0696", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reserved", "code_information": [ { "code": "0697", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reserved", "code_information": [ { "code": "0698", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Other Pre-hospice/Palliative", "code_information": [ { "code": "0699", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cast Room - General Classification", "code_information": [ { "code": "0700", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth abdominal wall surg", "code_information": [ { "code": "00730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth vasectomy", "code_information": [ { "code": "00921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth ear surgery", "code_information": [ { "code": "00120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth head/neck/ptrunk", "code_information": [ { "code": "00300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck organ 1yr/>", "code_information": [ { "code": "00320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of breast", "code_information": [ { "code": "00402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth correct heart rhythm", "code_information": [ { "code": "00410", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of shoulder", "code_information": [ { "code": "00450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct perfusion w/contrast cbf", "code_information": [ { "code": "0042T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone srgry cmptr fluor image", "code_information": [ { "code": "0054T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj ant sgm aq drg dev 1+", "code_information": [ { "code": "0671T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct perfusion w/contrast cbf", "code_information": [ { "code": "0042T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone srgry cmptr fluor image", "code_information": [ { "code": "0054T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj ant sgm aq drg dev 1+", "code_information": [ { "code": "0671T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "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) - Hospice", "code_information": [ { "code": "0125", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Three and Four Beds - Hospice", "code_information": [ { "code": "0135", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Deluxe Private - Hospice", "code_information": [ { "code": "0145", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Room & Board - Ward - Hospice", "code_information": [ { "code": "0155", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 1550, "methodology": "per diem", "median_amount": 1550, "10th_percentile": 1550, "90th_percentile": 1550, "count": "1 through 10" } ], "minimum": 1550, "maximum": 1550 } ] }, { "description": "Rehabilitation with CC/MCC", "code_information": [ { "code": "945", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1150, "methodology": "per diem", "median_amount": 1150, "10th_percentile": 1150, "90th_percentile": 1150, "count": "1 through 10" } ], "minimum": 1150, "maximum": 1150 } ] }, { "description": "Rehabilitation without CC/MCC", "code_information": [ { "code": "946", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "standard_charge_dollar": 1150, "methodology": "per diem", "median_amount": 1150, "10th_percentile": 1150, "90th_percentile": 1150, "count": "1 through 10" } ], "minimum": 1150, "maximum": 1150 } ] }, { "description": "Inpatient Renal Dialysis - Treatment", "code_information": [ { "code": "0805", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Continuation", "code_information": [ { "code": "0806", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Observation/Hourly", "code_information": [ { "code": "0807", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] }, { "description": "Inpatient Renal Dialysis - Other", "code_information": [ { "code": "0808", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "standard_charge_dollar": 400, "methodology": "fee schedule", "median_amount": 400, "10th_percentile": 400, "90th_percentile": 400, "count": "1 through 10" } ], "minimum": 400, "maximum": 400 } ] } ], "general_contract_provisions": [ { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Coventry Health Care", "plan_name": "Commercial Insured/Self-Insured", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Coventry Health Care", "plan_name": "Network Lease", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation Program", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Coventry Health Care", "plan_name": "Advantra Freedom", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "InterWest Health", "plan_name": "PPO", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO Network", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "GWH-CIGNA Network", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Cofinity", "plan_name": "PPO", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Humana Insurance Company", "plan_name": "HBHN Medicare Advantage", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Humana Insurance Company", "plan_name": "ChoiceCare Medicare Advantage", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Coventry Health Care", "plan_name": "Altius Advantra", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Wise Provider Networks", "plan_name": "PPO", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Blue Cross Blue Shield of Wyoming", "plan_name": "Commercial", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage Benefit Plans", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Individual Exchange (ACA)", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Coventry Health Care", "plan_name": "Automobile Insurance Compensation Program", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers' Compensation", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "DOL Workers' Comp", "plan_name": "Workers' Compensation", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial", "provision": "Stop loss enabled with no specific terms defined" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "High Plains", "provision": "Stop loss enabled with no specific terms defined" } ] }